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 A
Explanation
Choice A reason:
May operate a motor vehicle when no longer taking analgesics is appropriate. This option could still potentially be a concern. While the patient might not be taking analgesics, the halo device's restrictions on neck movement could still impact their ability to safely operate a motor vehicle. So, this option might still need clarification with the provider.
Choice B reason:
Increase Intake of fibre-rich foods. This option is not related to the use of a halo device. Increasing fibber intake is generally a positive dietary recommendation, and it doesn't directly pertain to the halo device or the patient's discharge instructions.
Choice C reason:
May place a small pillow under the head when sleeping. This option is incorrect because using a small pillow under the head when sleeping is a common practice for patients with halo devices. It helps to maintain proper alignment and reduce discomfort while sleeping.
Choice D reason:
Take tub baths instead of showers. This option is incorrect because taking tub baths instead of showers is a common recommendation for patients with halo devices. The halo device must be kept dry to prevent complications. Showering might increase the risk of water seeping into the halo vest, whereas taking a tub bath could help in maintaining dryness around the device.
Correct Answer is A
Explanation
Choice A Reason:
"I should use salt sparingly while cooking. “Response A indicates the client's understanding of the dietary teaching. Using salt sparingly while cooking is consistent with a low-sodium diet. It shows that the client recognizes the importance of reducing sodium intake to adhere to the prescribed dietary restrictions.
Choice B Reason:
"I can use baking soda when I bake" - Baking soda contains sodium and is not typically recommended for someone on a low-sodium diet.
Choice C Reason:
"I should use canned instead of frozen vegetables" - Canned vegetables often contain added sodium for preservation, so choosing fresh or frozen vegetables without added salt is a better option for a low-sodium diet.
Choice D Reason:
"I can season my foods with lemon juice" - Lemon juice is a suitable alternative to adding sodium for flavour, and this statement shows the client's understanding of using low-sodium seasoning options.
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