A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?
Apply light pressure proximal to the IV site.
Assess the radial pulse distal to the IV site.
Assist the client to straighten the right arm.
Elevate the client's right arm on one pillow.
The Correct Answer is C
A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.
B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.
C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.
D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.
B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.
C. Measuring urine output is important but secondary to assessing respiratory status.
D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.
Correct Answer is C
Explanation
A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.
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