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 C

Explanation

A. Urine output 20 mL/hr: A urine output of 20 mL/hr is on the low side but can still be expected in dehydration, as the body attempts to conserve water. Normal urine output is 30 mL/hr or more, so this could still be a sign of dehydration.

B. Sodium 142 mEq/L (136 to 145 mEq/L): This sodium level is within the normal range. Dehydration may cause sodium to be elevated if water loss is more significant than sodium loss, but a normal value does not indicate dehydration.

C. Cool skin: Cool skin is a typical finding in dehydration, particularly in severe cases, due to reduced peripheral circulation and vasoconstriction as the body tries to maintain core temperature and blood pressure.

D. Bradycardia: Dehydration usually causes tachycardia as a compensatory mechanism to maintain blood pressure and perfusion, not bradycardia.

A. "Adding pecans will be a change I can readily make." B. "I will eat cantaloupe for my morning snack." C. "I will miss eating yogurt every day for breakfast." D. "I can plan to eat rice instead of baked potatoes."

Correct Answer is B

Explanation

A. "Adding pecans will be a change I can readily make.": Pecans are not a significant source of potassium compared to other foods.

B. "I will eat cantaloupe for my morning snack.": Cantaloupe is a potassium-rich food and an excellent choice to increase dietary potassium.

C. "I will miss eating yogurt every day for breakfast.": Yogurt is a good potassium source, so discontinuing it would not help.

D. "I can plan to eat rice instead of baked potatoes.": Rice is low in potassium, whereas baked potatoes are a potassium-rich option.

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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

A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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