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
Explanation
A) "My child has some swelling around her eyelids and mouth."
In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.
The other findings, while important, are not as immediately concerning:
B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.
C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.
D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.
Correct Answer is B
Explanation
Choice A rationale:
Acetone breath is a symptom of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. It occurs due to the presence of ketones in the breath and is not specific to hypoglycemia. Hypoglycemia is characterized by low blood sugar levels, not elevated ketone levels.
Choice B rationale:
Confusion is a common symptom of hypoglycemia. When blood sugar levels drop significantly, the brain may not receive enough glucose to function properly, leading to confusion, dizziness, and other neurological symptoms.
Choice C rationale:
Polydipsia refers to excessive thirst and is a symptom of hyperglycemia (high blood sugar levels), not hypoglycemia. In hyperglycemic states, the body tries to eliminate excess glucose through urine, leading to increased thirst.
Choice D rationale:
Hot, dry skin is not a typical symptom of hypoglycemia. Hypoglycemia can cause diaphoresis (excessive sweating) and cool, clammy skin due to the body's stress response.
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