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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging the client to use nearby furniture is unsafe for a client on complete bed rest.
B. Physical therapy is not typically called to assist with bathroom use for an end-of-life client.
C. This response acknowledges the client’s emotional state and opens communication to address their concerns empathetically.
D. Telling the client they "have to" use a bed pan without further discussion may come across as dismissive or insensitive.
Correct Answer is ["A","B","C","D","E"]
Explanation
Nurses' Notes
0900:
Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."
Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:
General: tearful, anxious
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant
FHR: 116/min, minimal variability noted
Rationale:
Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.
Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.
Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.
FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.
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