A nurse is caring for a client.

Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.

It is recommended that IVs are placed in the arm on the opposite side of your surgery, if possible.

Choice A is wrong because it involves placing the IV catheter on the same side as the mastectomy.
Choice C is wrong because it involves placing the IV catheter on the same side as the mastectomy.
Choice D is wrong because it involves placing the IV catheter on a vein that is not commonly used for IV therapy.

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.