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 C
Explanation
A. Infusion pump and IV site: Necessary but not priority for safety during epidural initiation.
B. Level of pain sensation: Important for effectiveness but not as urgent as monitoring for hypotension.
C. Maternal blood pressure (BP): Epidural anesthesia can cause vasodilation and maternal hypotension, which can compromise fetal oxygenation.
D. Variability of fetal heart rate: Important but affected indirectly by maternal BP; BP is assessed first.
Correct Answer is B
Explanation
A. Withhold the medication and notify the charge nurse: Not needed; goiter is common in hypothyroidism, and there are no swallowing/breathing issues.
B. Administer the oral medication with a glass of water as scheduled: No contraindication; continue therapy as prescribed.
C. Place the client on NPO status: Not indicated unless airway compromise or swallowing difficulty is present.
D. Crush the medication and mix with applesauce: Levothyroxine should be taken whole with water on an empty stomach for optimal absorption.
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