A nurse is preparing to initiate intravenous fluids via infusion pump for a client.
Which of the following actions should the nurse take?
Check the expiration date on the safety inspection sticker of the pump.
Verify that the extension cord for the pump is ungrounded.
Report the pump has a frayed cord and proceed with the infusion.
Obtain a surge protector that can accommodate the pump and several other appliances.
The Correct Answer is A
Choice A rationale:
(Correct Choice) Checking the expiration date on the safety inspection sticker of the pump is essential to ensure the equipment is functioning properly and safely. Using expired equipment can compromise the client's safety and the effectiveness of the treatment.
Choice B rationale:
Verifying that the extension cord for the pump is ungrounded is important for electrical safety. However, it is not the nurse's responsibility to do this. This action should be performed by a qualified electrician or facility maintenance personnel.
Choice C rationale:
Reporting the pump with a frayed cord is essential. However, it is not safe to proceed with the infusion in this situation. Using damaged equipment can lead to electrical hazards and compromise the client's safety.
Choice D rationale:
Obtaining a surge protector is important for protecting the pump and other electrical appliances from power surges. While this is a good practice, it is not the first action the nurse should take when preparing to initiate intravenous fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F","G"]
Explanation
The correct answers are Choices A, C, D, E, F, and G.
Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.
Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.
Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.
Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.
Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.
Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.
Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.
Correct Answer is C
Explanation
Answer is c. Keep visitors at least 6 feet (1.8 m) away from the client.
a. Place the client's soiled bed linens in a biohazard bag outside the client's room: While it is essential to follow standard precautions for handling potentially contaminated linens, soiled bed linens from a client undergoing brachytherapy do not require special handling in a biohazard bag unless contaminated with blood or bodily fluids. Brachytherapy involves the internal placement of radioactive sources near or within the tumor site, but the risk of contamination from bodily fluids is minimal. Therefore, soiled linens can be managed according to standard facility protocols for handling linens.
b. Wear an isolation gown when caring for the client: This option is incorrect because wearing an isolation gown is not necessary for radiation safety during brachytherapy. Radiation exposure is primarily managed through the use of lead aprons, gloves, and other shielding devices when directly handling radioactive sources or being in close proximity to the client during treatment sessions. Isolation gowns are typically used to prevent the spread of infection and are not specifically designed to shield against radiation exposure.
c. Keep visitors at least 6 feet (1.8 m) away from the client: Correct. This action minimizes radiation exposure to visitors, as brachytherapy involves the internal placement of radioactive material near or within the tumor site. Maintaining a distance of at least 6 feet (1.8 meters) from the client helps reduce the risk of radiation exposure to visitors while allowing them to provide support and companionship to the client. Visitors should also be informed about radiation safety precautions and instructed to limit their time spent near the client during treatment.
d. Discard the radioactive source in the client's trash can: This option is incorrect because radioactive sources used in brachytherapy must be handled and disposed of by trained personnel following established radiation safety protocols. Disposing of radioactive material in a client's regular trash can poses significant risks of exposure to others and is not permitted. Proper disposal procedures for radioactive sources involve packaging them in approved containers and returning them to the facility's radiation safety department for appropriate disposal or recycling.
In summary, the correct answer is c because keeping visitors at least 6 feet (1.8 meters) away from the client helps minimize their radiation exposure during brachytherapy, which involves the internal placement of radioactive material near or within the tumor site. This action aligns with radiation safety principles and helps protect both the client and visitors from unnecessary radiation exposure.
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