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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.
B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.
C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.
D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

A. Obtain a blood pressure every 15 minutes. B. Monitor the client's complete blood count (CBC) daily. C. Review creatinine and blood urea nitrogen results. D. Measure the client's urinary output daily.

Correct Answer is A

Explanation

A. Dopamine, a sympathomimetic agent, can cause significant changes in blood pressure. Monitoring blood pressure every 15 minutes is crucial to assess the client's response to the medication and to detect any adverse effects, such as hypertension or hypotension, promptly.
B. Monitoring CBC is important but not as immediately critical in this situation as monitoring blood pressure.
C. While reviewing creatinine and BUN results is important for overall kidney function, it is not the most immediate priority when administering dopamine for shock.
D. Measuring urinary output is important for assessing renal perfusion but should be done more frequently than daily in a client receiving dopamine for shock.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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