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).

Choice A rationale The administration of excessive IV fluids is a medication error that has the potential to cause significant harm to the client, such as fluid overload and heart failure. The provider must be contacted immediately to assess the client's condition, order appropriate interventions, and adjust the plan of care to address the error and its effects. Choice B rationale The charge nurse is a crucial member of the healthcare team who needs to be informed of any significant errors. Reporting the error to the charge nurse ensures that they are aware of the situation, can provide support to the nurse involved, and can assist in coordinating the necessary actions and resources to ensure client safety. Choice C rationale An incident report is a formal document used to report adverse events, medication errors, or near-misses. It serves to improve quality of care and identify system issues. The report should never be placed in the client's medical chart; instead, it is a risk management tool that should be filed separately to avoid becoming part of the legal medical record. Choice D rationale Excessive IV fluid administration can lead to fluid volume overload. This condition can cause fluid to shift into the interstitial spaces of the lungs, resulting in pulmonary edema. Auscultating the client's lungs for crackles or rales is a critical step to assess for this potentially life-threatening complication and guide immediate interventions. Choice E rationale Peripheral edema is a clinical sign of fluid volume overload. The excess fluid shifts from the intravascular space into the interstitial tissues, particularly in dependent areas like the ankles and sacrum. Checking for peripheral edema provides an important physical assessment finding that helps confirm the presence and severity of fluid volume excess.