A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first?
Reposition the client's left arm.
Check the IV site for redness.
Ensure the tubing connections are secure.
Flush the IV catheter
The Correct Answer is C
Choice A Reason:
Repositioning the client's left arm is incorrect. Repositioning the arm might help prevent kinks or occlusions in the tubing, but addressing the tubing connections comes first.
Choice B Reason:
Checking the IV site for redness is incorrect. Checking for redness is important to assess for signs of infection or inflammation, but it can wait until after addressing the tubing issue.
Choice C Reason:
Ensuring the tubing connections are secure is correct. When the infusion pump alarms, the first step is to ensure that the tubing connections are secure. A loose or disconnected tubing can lead to interrupted or inadequate infusion, which could affect the client's treatment and well-being. By checking and securing the tubing connections, the nurse can address any immediate issues related to the alarm.
Choice D Reason:
Flushing the IV catheter is incorrect - Flushing the catheter might be necessary if there are blockages or if medications need to be administered, but addressing the tubing connections is the immediate priority when the infusion pump alarms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I can give you a list of other people who had the same procedure." - This response might not address the client's concerns and could potentially violate privacy and confidentiality.
Choice B Reason:
"I can give you additional information about the procedure." Response B is an appropriate and supportive response. The client is expressing uncertainty about the mastectomy, so offering more information about the procedure can help the client make an informed decision. Providing accurate and detailed information allows the client to better understand their options and the potential benefits and risks of the procedure.
Choice C Reason:
"You will be cancer-free if you have the procedure." - Making a guarantee of being cancer-free after the procedure might be misleading and overly optimistic. While a mastectomy can treat cancer in some cases, it's important to provide realistic information.
Choice D Reason:
"You should get a second opinion regarding the procedure." - While seeking a second opinion can be valuable, this response might not directly address the client's immediate concerns about the procedure. Providing information first and then discussing the option of a second opinion might be a more balanced approach.
Correct Answer is B
Explanation
Choice A Reason:
Gently massage the area around the client's incision is not recommendable. Massage may not be suitable for a recently operated area and could potentially worsen pain and disrupt the healing process.
Choice B Reason:
Apply an ice pack to the client's knee is recommendable. Applying an ice pack to the client's knee can help reduce pain and inflammation following a total knee arthroplasty. Ice can help numb the area and reduce swelling, providing relief to the client's discomfort. It's important to use a barrier, such as a cloth or towel, between the ice pack and the skin to prevent frostbite.
Choice C Reason:
Perform range-of-motion exercises to the client's knee is not recommendable. Range-of-motion exercises may be beneficial for recovery, but they might not be appropriate at this pain level. Pain should be managed before engaging in such activities.
Choice D Reason:
Place pillows under the client's knee is recommendable. Elevating the knee might help with comfort, but addressing the pain directly should be the priority.
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