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    Ati Lpn Comprehensive Predictor 2023 Proctored Exam

    A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?

    Explanation & Rationale

    A. Collect data on the client: After stopping the infusion, the nurse’s priority is to assess the client for signs of fluid overload or adverse effects, such as changes in lung sounds, edema, blood pressure, heart rate, or respiratory status. Early assessment identifies physiologic compromise and guides urgent interventions. B. Notify the provider: The provider must be informed once the client’s condition has been assessed and relevant data are available. Providing objective findings allows the provider to determine the need for additional orders, such as diuretics or laboratory tests. Notification without assessment limits effective clinical decision-making. C. Notify the unit manager: Informing the unit manager is part of the administrative follow-up related to the medication or infusion error. This action supports quality improvement and policy adherence but does not directly address the client’s immediate physiologic risk. D. Complete an incident report: An incident report is required to document the error and support system-level prevention strategies. It is completed after ensuring the client is stable and appropriate notifications have been made. This does not contribute to immediate client assessment or stabilization.

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