A nurse is admitting a client transferred from another facility. On assessment, the nurse notices the epidural IV tubing is attached to a bag of dextrose-containing IV fluid and the IV line is connected to an epidural pump containing morphine. What actions by the nurse take priority? (Select all that apply.)

Question

Quizplus · Accepted Answer

The first thing the nurse would do is to discontinue the fluids that are going into the wrong lines, then conduct a respiratory assessment because IV opioid administration can cause respiratory depression. There is no indication that this client is in distress at this point, so the Rapid Response Team is not needed; however, the nurse would request assistance from other staff. If the client were in distress, the nurse would call or delegate calling the RRT. A full head-to-toe assessment can wait until the client is stable. The nurse would complete the variance report as soon as care the client has been cared for appropriately.

A Nurse Is Admitting a Client Transferred from Another Facility