A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?
Apply light pressure proximal to the IV site.
Assess the radial pulse distal to the IV site.
Assist the client to straighten the right arm.
Elevate the client's right arm on one pillow.
The Correct Answer is C
A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.
B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.
C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.
D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.
Correct Answer is C
Explanation
A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.
B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.
C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.
D. Checking capillary glucose levels is not relevant to the assessment of jaundice.
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