The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Turn off the IV solution and gently flush the line with 3 mL of saline flush solution.

Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution.

Notify the physician

Check for kinking of the tubing or a closed clamp.

Answer and Explanation

The Correct Answer is D

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

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Correct Answer is B

Explanation

A. Sodium level 140 mEq/L (136-145 mEq/L): This sodium level is within the normal range and is not of concern.

B. Magnesium level 1.0 mEq/L (1.3-2.1 mEq/L): This value is below the normal range, indicating hypomagnesemia, which can cause serious complications such as arrhythmias, neuromuscular irritability, and seizures. This is the most concerning value.

C. Calcium level 10 mg/dL (9-10.5 mg/dL): This calcium level is within the normal range and is not concerning.

D. Potassium level 3.5 mEq/L (3.5-5 mEq/L): This potassium level is at the low end of normal. While it is something to monitor, it is not immediately concerning compared to hypomagnesemia.

A. Skeletal muscle weakness B. Decreased deep-tendon reflexes C. Tingling of the lips D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. Skeletal muscle weakness: This is more commonly seen with hypercalcemia, not hypocalcemia. Hypocalcemia typically causes neuromuscular irritability, which manifests as muscle spasms rather than weakness.

B. Decreased deep-tendon reflexes: This is more commonly seen with hypercalcemia. Hypocalcemia typically increases neuromuscular irritability and can cause hyperactive reflexes.

C. Tingling of the lips: This is a classic sign of hypocalcemia, as low calcium levels can lead to neuromuscular excitability, which can cause sensations like tingling (paresthesia) around the lips and fingers.

D. Hypoactive bowel sounds: Hypocalcemia typically increases bowel motility, which can lead to hyperactive bowel sounds, not hypoactive bowel sounds.

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The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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