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.)
Contact the provider.
Report the error to the charge nurse.
Place an incident report in the client’s chart.
Auscultate the client’s lungs.
Check the client for peripheral edema.
Correct Answer : A,B,D,E
Choice A rationale
Contacting the provider is essential to inform them of the error and receive further instructions on managing the client’s condition.
Choice B rationale
Reporting the error to the charge nurse is necessary for proper documentation and to ensure that corrective actions are taken to prevent future errors.
Choice C rationale
Incident reports should not be placed in the client’s chart. They are for internal use to improve safety and quality of care.
Choice D rationale
Auscultating the client’s lungs is important to check for signs of fluid overload, such as crackles or wheezing.
Choice E rationale
Checking for peripheral edema helps assess the extent of fluid overload and its impact on the client’s condition.
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Correct Answer is ["A","F"]
Explanation
Choice A rationale
Thrombocytopenia, a low platelet count, increases the risk of bleeding and hemorrhage when receiving heparin.
Choice B rationale
Neutropenia, a low white blood cell count, does not directly increase the risk of hemorrhage. It is more related to infection risk.
Choice C rationale
Hypokalemia, low potassium levels, does not directly indicate a risk for hemorrhage. It can cause other complications but not specifically bleeding.
Choice D rationale
Fever is not a direct indicator of hemorrhage risk. It may indicate infection or other inflammatory processes.
Choice E rationale
Hyperglycemia, high blood sugar levels, does not indicate a risk for hemorrhage. It is more related to diabetes management.
Choice F rationale
Dark stools can indicate gastrointestinal bleeding, which is a sign of hemorrhage.
Correct Answer is C
Explanation
Choice A rationale
Metoclopramide is not used to suppress cough. It is primarily used to treat nausea, vomiting, and gastroparesis.
Choice B rationale
Metoclopramide does not have a primary effect on muscle relaxation. Its main action is to increase gastrointestinal motility.
Choice C rationale
Reduced nausea is a primary outcome for evaluating the effectiveness of metoclopramide. It is commonly prescribed to manage nausea and vomiting.
Choice D rationale
Metoclopramide is not typically used to decrease pain. Its primary indications are related to gastrointestinal symptoms.