A nurse is caring for a client who has a prescription for a peripheral IV catheter.

After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?

The correct answer is b. Remove the device from the room.

Choice A rationale:

• Reporting the defect to the equipment maintenance staff is essential,but it's not the immediate priority.The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
• Delaying the removal of the device could lead to electrical shock,fire,or other serious consequences.
• Therefore,removing the device from the room takes precedence over reporting the defect.

Choice B rationale:

• Removing the device from the room is the most appropriate first action because it:
  • Eliminates the immediate safety hazard.
  • Prevents potential harm to the client and others.
  • Protects the device from further damage.
  • Ensures the safety of the environment.
  • Demonstrates the nurse's prioritization of patient safety.

Choice C rationale:

• Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
• However,it's not the first action because it doesn't address the immediate safety concern.
• The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.

Choice D rationale:

• Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
• However,it's not relevant to the immediate safety issue of the frayed cord.
• The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
• The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.

This prescription is complete because it includes the medication name, dose, route, and frequency.

A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.

Choice A is wrong because it does not specify the dose of cimetidine.

PO twice daily is not enough information to administer the medication safely.

Choice B is wrong because it does not specify the frequency of tetracycline.

200 mg PO is not enough information to administer the medication safely.

Choice C is wrong because it does not specify the route of epoetin alfa.

150 units/kg three times weekly is not enough information to administer the medication safely.

Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.

Normal ranges for cimetidine are 50 to 150 ng/mL.

Normal ranges for tetracycline are 1 to 10 mcg/mL.

Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.