The practical nurse (PN) finds a client who is assigned to another nurse bleeding from an IV site and the IV tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding. Which action should the PN take next?
Tell the nurse assigned to the client about the event so the findings can be recorded.
Enter computer documentation of the findings and the application of a dressing.
Inform the charge nurse that the findings indicate that the client pulled out the IV.
Complete the shift documentation for this client and include the findings about the IV.
The Correct Answer is A
A. Tell the nurse assigned to the client about the event so the findings can be recorded: The PN must first verbally report to the responsible nurse to ensure continuity of care and proper documentation.
B. Enter computer documentation of the findings and the application of a dressing: Documentation is essential but comes after notifying the primary nurse in charge of the client.
C. Inform the charge nurse that the findings indicate that the client pulled out the IV: Assumptions should be avoided unless confirmed; the PN should report only observed facts.
D. Complete the shift documentation for this client and include the findings about the IV: This delays immediate communication to the responsible nurse and could jeopardize timely care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Late Middle adulthood:
Calcium intake is important at all ages, but prevention is most effective before peak bone mass is reached.
B. Late adulthood:
At this stage, bone loss prevention is still important, but most peak bone mass has already been lost.
C. Middle adulthood:
Bone mass maintenance continues, but the critical period for maximizing peak bone mass is earlier.
D. Early adulthood:
Bone mass peaks by the late 20s; maximizing calcium intake during early adulthood helps prevent osteoporosis later.
Correct Answer is A
Explanation
A. Give 4 oz (120 mL) of apple juice:
Diaphoresis, confusion, and “not feeling right” indicate hypoglycemia. Rapid-acting carbohydrates should be given immediately if the client can swallow.
B. Administer glucagon 0.5 mg IM:
Used if the client is unconscious or unable to swallow safely.
C. Assess temperature:
Does not address the immediate risk of hypoglycemia.
D. Evaluate deep tendon reflexes:
Not relevant to urgent management of suspected hypoglycemia.
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