A nurse is caring for a client and notices fraying on the electrical cord of the client fall. The charge nurse should identify that which of the following nurse to take?
Request a replacement IV pump.
Remove the IV pump from the client's room.
Check the expiration date of the inspection sticker.
Report the problem to the engineering team.
None
None
The Correct Answer is B
A. While obtaining a replacement is necessary, the immediate priority is ensuring client safety by removing the hazardous equipment first.
B. A frayed electrical cord poses a safety hazard, including the risk of electrical shock, fire, or equipment malfunction. The first priority is to remove the faulty equipment from the client’s environment to prevent potential harm. After removing the IV pump, the nurse should report the issue to the appropriate department, such as engineering or biomedical services, for repair or replacement.
C. This does not directly address the safety risk posed by the frayed cord.
D. While reporting is necessary, the first action should be to remove the unsafe equipment to eliminate immediate danger.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client's preferred time for bathing: While this information may be relevant to the client's care, it is not typically included in a change-of-shift report unless it directly impacts the client's medical condition or care plan.
B. The time the client received his last dose of pain medication: This information is crucial for ensuring continuity of care and managing the client's pain appropriately during the transfer to the rehabilitation facility.
C. The belief that the client has a difficult relationship with his son: While psychosocial factors can impact a client's care, this information may not be relevant to the client's immediate medical needs or the transition to the rehabilitation facility.
D. The steps to follow when providing wound care: While wound care instructions are important, they are typically documented in the client's medical record and may not need to be included in a change-of-shift report unless there are specific wound care concerns that need to be addressed during the transfer.
Correct Answer is A
Explanation
A. Elevating the head of the client’s bed to 30° before inserting a nasogastric (NG) tube is incorrect. The proper position for NG tube insertion is typically with the client sitting upright at 45–90° to reduce the risk of aspiration and facilitate the passage of the tube through the esophagus. This action requires intervention by the charge nurse to correct the positioning.
B. Maintaining the chest tube collection device below the level of the insertion site when ambulating the client is correct. This positioning prevents backflow of drainage into the pleural space, which could lead to complications such as pneumothorax or infection. No intervention is needed for this action.
C. Assisting the client into a fetal position on their side in preparation for a lumbar puncture is correct. This position helps to widen the spaces between the vertebrae, allowing easier access to the spinal canal for the procedure. This action does not require intervention.
D. Assessing the client’s gag reflex following an esophagogastroduodenoscopy (EGD) is correct. After an EGD, the client’s gag reflex must return before allowing oral intake to prevent aspiration. This action does not require intervention.
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