A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?

Unplug the pump.

Notify the biomedical department to fix the pump.

Label the pump with a defective equipment sticker.

Obtain a replacement pump.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Unplugging the pump is the first action to eliminate the immediate risk of sparks and prevent potential electrical hazards.

Choice B rationale:

Notifying the biomedical department is important but should be done after ensuring the immediate safety of the client.

Choice C rationale:

Labeling the pump with a defective equipment sticker is appropriate but does not address the immediate risk.

Choice D rationale:

Obtaining a replacement pump is a reasonable step, but unplugging the malfunctioning pump takes precedence to prevent any electrical hazards.

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Correct Answer is A

Explanation

Choice A rationale:

This will reduce splashing and aerosolization of the solution. This prevents contamination of the solution and the sterile field by keeping a safe distance from the bowl.

Choice B rationale:

Sterile gloves should be applied after the sterile field is established to prevent contamination. This will prevent contamination of the gloves by touching the outside of the bottle.

Choice C rationale:

the nurse should place the lid of the sterile solution bottle face up on a separate sterile drape, not face down on the same drape. This will prevent contamination of the lid and the drape by touching each other.

Choice D rationale:

the nurse should hold the bottle of sterile solution so that the label is facing away from the palm of the hand, not towards it. This will prevent the label from getting wet and unreadable.

A. Comfort level B. Skin integrity C. Elimination needs D. Peripheral pulses

Correct Answer is D

Explanation

Choice A rationale:

Assessing comfort level is important, but assessing peripheral pulses takes precedence to ensure the client's safety and prevent complications.

Choice B rationale:

Assessing skin integrity is relevant but secondary to assessing peripheral pulses. Skin integrity can be addressed after ensuring adequate circulation.

Choice C rationale:

Assessing elimination needs is not the priority in this context. While it's important to address overall care needs, assessing peripheral pulses is more critical in preventing complications related to restraints.

Choice D rationale:

Assessing peripheral pulses is the priority when caring for a client with restraints to each extremity. Monitoring circulation ensures that blood flow is maintained, and complications related to impaired circulation are promptly identified.

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A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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