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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.

Choice B reason:

Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.

Choice C reason:

Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.

Choice D reason:

Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.

A. The client reports being extremely thirsty with a sore throat. B. The client's abdomen becomes distended and firm. C. The drainage is bright green in color with brown fecal material D. The amount of drainage is gradually decreasing

Correct Answer is C

Explanation

Choice A Reason:

The client reports being extremely thirsty with a sore throat - This could be due to the presence of the NG tube and suctioning, but it is not as immediately concerning as the change in drainage colour.

Choice B Reason:

The client's abdomen becomes distended and firm - While this could indicate a possible complication, it is not as directly related to the change in drainage colour.

Choice C Reason:

The drainage is bright green in colour with brown faecal material the finding that the drainage from the NG tube is bright green in colour with brown faecal material should be reported to the provider. This change in the colour and appearance of the drainage can be indicative of bilious (greenish-yellow) vomiting, which may suggest an obstruction or another underlying issue. It's important to assess the client's condition and inform the provider about any significant changes in their symptoms.

Choice D Reason:

The amount of drainage is gradually decreasing - Gradually decreasing drainage could be expected as the condition improves, but it's not as alarming as a change in the drainage colour.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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