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    Ati Rn Capstone Pharmacology 1 Proctored Exam(Benchmark)
    Select All That Apply

    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.)

    Explanation & Rationale

    A. "Contact the provider": The nurse should immediately contact the provider to report the error and receive guidance on any necessary interventions, such as adjusting fluid balance or addressing complications. B. "Report the error to the charge nurse": It is essential to inform the charge nurse about the error. This ensures appropriate steps are taken within the facility and helps improve communication and safety protocols. C. "Place an incident report in the client's chart": An incident report should be filed, but it should not be placed in the client’s chart. Incident reports are typically filed separately to maintain objectivity and ensure accurate documentation of the error outside of the client’s medical record. D. "Auscultate the client's lungs": Excessive IV fluids can lead to fluid overload and pulmonary edema. Auscultating the lungs for crackles or abnormal sounds is critical to assess the client's respiratory status. E. "Check the client for peripheral edema": Peripheral edema is another sign of fluid overload. The nurse should check for swelling in the extremities as part of the assessment to identify any complications of excessive fluid administration.

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