Difficulty: Medium
Average Score: 84%
Simulated
A nurse is caring for a client who received excessive IV fluids in error. Which of the following actions should the nurse take? (Select all that apply.)
Correct answer
A,B,D,E
Rationale
Correct Answer: A, B, D, E
Rationale:
A: Contact the provider - The nurse should inform the provider immediately to address the excessive IV fluid administration.
B: Report the error to the charge nurse - Reporting to the charge nurse ensures proper documentation and initiation of corrective measures.
D: Auscultate the client's lungs - Excessive IV fluids can lead to pulmonary edema, so auscultating the lungs helps in assessing for any signs of fluid overload.
E: Check the client for peripheral edema - Peripheral edema is a common sign of fluid overload, which can result from excessive IV fluids.
Summary:
C: Placing an incident report in the client's chart is not as urgent as directly informing the provider and charge nurse.
F: There is no information provided on option F.
G: There is no information provided on option G.
Rationale:
A: Contact the provider - The nurse should inform the provider immediately to address the excessive IV fluid administration.
B: Report the error to the charge nurse - Reporting to the charge nurse ensures proper documentation and initiation of corrective measures.
D: Auscultate the client's lungs - Excessive IV fluids can lead to pulmonary edema, so auscultating the lungs helps in assessing for any signs of fluid overload.
E: Check the client for peripheral edema - Peripheral edema is a common sign of fluid overload, which can result from excessive IV fluids.
Summary:
C: Placing an incident report in the client's chart is not as urgent as directly informing the provider and charge nurse.
F: There is no information provided on option F.
G: There is no information provided on option G.