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:
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.
Choice B Reason:
A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.
Choice CReason:
A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.
Choice DReason:
A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.
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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