A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

Complete an incident report and place it in the client's medical record.

Compare the current infusion with the prescription in the client's medication record.

Contact the charge nurse to see if the prescription was changed.

Submit a written warning for the nurse involved in the incident.

Answer and Explanation

The Correct Answer is B

A. An incident report is appropriate but should not be placed in the client’s medical record.

B. The nurse should first compare the current infusion with the prescription in the client's medication record to ensure the client is receiving the correct medication and dosage.

C. The nurse should verify the prescription before contacting the charge nurse.

D. Submitting a written warning is not the nurse's responsibility and is not appropriate in this situation.

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Correct Answer is ["B","D","E"]

Explanation

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

A. Hypotension B. Tachycardia C. Dyspnea D. Dry cough

Correct Answer is C

Explanation

A. Hypotension is a concern but may occur for various reasons and is not as immediately life-threatening as dyspnea.

B. Tachycardia can indicate a problem but is less urgent than respiratory distress.

C. Dyspnea is the priority as it may indicate a recurrence of pulmonary embolism or another life-threatening respiratory issue.

D. A dry cough is a less urgent symptom and does not require immediate reporting.

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A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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