After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Document the event in the electronical health record.

Complete an incident report.

Inform the nurse on the next shift.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is B

A.   Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B.   When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C.   While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D.   Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

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Correct Answer is A

Explanation

A. Reporting the findings to the healthcare provider is crucial in this situation. The combination of fever and dyspnea could indicate a serious complication such as aspiration pneumonia or an infection related to the tube feeding. Prompt communication with the healthcare provider ensures that the client receives timely evaluation and treatment.
B. While monitoring electrolytes is important in the context of tube feedings (to ensure proper balance and prevent imbalances), the symptoms of fever and dyspnea are more urgent concerns that need immediate attention.
C. Using an incentive spirometer can be beneficial for improving lung function and preventing complications like atelectasis, especially if the client has respiratory issues. However, this action is more appropriate for clients who have specific respiratory therapy needs and is not the first step in addressing acute symptoms like fever and dyspnea, which require a more immediate response.
D. Connecting the tube to low intermittent suction might be used to manage gastric residuals or to help with gastrointestinal decompression in some situations, but it does not address the acute symptoms of fever and dyspnea.

A. Use a belt restraint to secure the client in the chair. B. Empty the client's urinary drainage bag. C. Reposition the client's urinary drainage bag. D. Elevate the client's feet higher on the foot rests.

Correct Answer is C

Explanation

A. Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B. Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C. Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D. Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

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After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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