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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.
B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.
C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.
D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.
Correct Answer is B
Explanation
A. The patient can experience speed shock: Speed shock is a rapid infusion of a substance (like a medication or fluid) into the bloodstream, usually occurring when the infusion rate is too fast. This is not typically caused by flushing a clotted cannula.
B. A clot can be forced into the circulation causing serious complications: Flushing a clotted cannula too aggressively can dislodge a clot, causing it to travel into the bloodstream. This can lead to serious complications like embolism or stroke, especially if the clot is large or travels to a vital organ.
C. A painful arterial spasm can occur: While arterial spasms can occur, they are more often related to arterial catheterization or manipulation rather than flushing a venous cannula.
D. The catheter can become dislodged and fall out: While this could potentially happen, it is less of a concern compared to the risk of pushing a clot into circulation, which is a more immediate danger.
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