A nurse is caring for a client.

Exhibit 1 Nurses' Notes Day 1: Exhibit 2 Exhibit 3 Client reports fatigue, weight loss, night sweats, and a persistent cough.

Performed a purified protein derivative test on the client and obtained a QuantiFERON-TB Gold blood test as prescribed.

Bilateral breath sounds with crackles and scattered wheezes throughout.

Cough productive for yellow, purulent sputum.

What are the first two actions the nurse should take?

In general, parental (or legal guardian) consent is required for any diagnostic or surgical procedure performed on a child under the age of 181.
Choice A is wrong because the mother’s 21-year-old sibling is not a parent or legal guardian of the infant.
Choice B is wrong because the infant’s provider cannot sign the consent form on behalf of the infant.
Choice C is wrong because the infant’s grandparent cannot sign the consent form unless they are a legal guardian of the infant.

The correct answer is d. Unplug the pump.

Rationale for Choice A:

• While notifying the biomedical department to fix the pump is important,it is not the immediate priority in this situation.The first step is to ensure patient and staff safety by removing the potential electrical hazard.
• Delaying the removal of the sparking pump could lead to electrical shock,fire,or other serious consequences.
• Biomedical staff can be notified after the immediate safety risk has been addressed.

Rationale for Choice B:

• Obtaining a replacement pump is necessary to continue the client's IV therapy,but it is not the first action the nurse should take.
• The priority is to eliminate the electrical hazard posed by the sparking pump.
• Once the faulty pump is unplugged and safety is ensured,the nurse can then proceed to obtain a replacement pump.

Rationale for Choice C:

• Labeling the pump with a defective equipment sticker is important to prevent others from using it,but it does not address the immediate safety risk.
• The priority is to disconnect the pump from the power source to eliminate the risk of electrical shock or fire.
• Labeling can be done after the pump has been unplugged and the situation has been assessed.

Rationale for Choice D:

• Unplugging the pump is the correct first action because it immediately removes the electrical hazard,preventing potential harm to the patient,staff,or equipment.
• This action prioritizes safety and mitigates the risk of electrical shock,burns,fire,or other serious consequences.
• It is essential to act quickly and decisively in such situations to ensure a safe environment for everyone involved.