An older client with a continuous peripheral infusion in the antecubital fossae site is reporting that the infusion pump keeps beeping. The practical nurse (PN) determines the pump is displaying a digital alarm reading, "occlusion." Which client assessment should the PN perform first?

Check for swelling underneath the elbow.

Measure fluid intake and output.

Compare the radial pulse volume bilaterally.

Assess range of motion of the joint.

Answer and Explanation

The Correct Answer is A

A. Check for swelling underneath the elbow: Swelling suggests infiltration or extravasation, which is a common cause of occlusion alarms and must be assessed immediately.
B. Measure fluid intake and output: Not directly related to resolving the occlusion alarm.
C. Compare the radial pulse volume bilaterally: Not relevant to the occlusion alarm.
D. Assess range of motion of the joint: May identify kinking from joint movement but swelling should be checked first.

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Correct Answer is B

Explanation

A. Withhold the medication and notify the charge nurse: Not needed; goiter is common in hypothyroidism, and there are no swallowing/breathing issues.
B. Administer the oral medication with a glass of water as scheduled: No contraindication; continue therapy as prescribed.
C. Place the client on NPO status: Not indicated unless airway compromise or swallowing difficulty is present.
D. Crush the medication and mix with applesauce: Levothyroxine should be taken whole with water on an empty stomach for optimal absorption.

A. Several dime-sized circular burns on the back. B. Refusal to answer simple questions. C. One-inch laceration across center of forehead. D. Small bruises on the lower extremities.

Correct Answer is A

Explanation

A. Several dime-sized circular burns on the back:
Highly suspicious for abuse; requires immediate intervention and reporting.

B. Refusal to answer simple questions:
May be fear or shyness; not as urgent as evidence of abuse.

C. One-inch laceration across center of forehead:
May occur with typical toddler activity; assess but not as high-priority for abuse suspicion.

D. Small bruises on the lower extremities:
Common in active toddlers; less suspicious for abuse.

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An older client with a continuous peripheral infusion in the antecubital fossae site is reporting that the infusion pump keeps beeping. The practical nurse (PN) determines the pump is displaying a digital alarm reading, "occlusion." Which client assessment should the PN perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is preparing to administer levothyroxine 25 mcg PO daily to a newly admitted client with hypothyroidism. The PN observes that the client's neck is enlarged, but the client denies pain or difficulty swallowing. Which action should the PN take?

Correct Answer is B

Explanation

The practical nurse (PN) is assisting with screening examinations at a community clinic where a toddler is brought by a parent for scheduled vaccines. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the PN?

Correct Answer is A

Explanation

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