A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first?
Check the IV site for redness.
Ensure the tubing connections are secure.
Reposition the client's left arm.
Flush the IV catheter.
The Correct Answer is C
This is because the most common cause of infusion pump alarms is occlusion or obstruction of the IV line, which can be due to kinking, bending, or compression of the tubing or catheter by the client's arm or body position. By repositioning the client's arm, the nurse can relieve the occlusion and restore the flow of the IV fluid.
This action should be done before checking for other possible causes of alarm, such as redness at the IV site (which could indicate infection or inflammation), loose tubing connections (which could cause leakage or air embolism), or clogged IV catheter (which could require flushing with saline or heparin solution).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Drinking plenty of fluids helps flush out bacteria from the urinary tract and prevent urinary stasis . Wiping from front to back prevents contamination of the urethra with fecal bacteria . Cranberry juice may prevent bacterial adherence to the bladder wall and lower the pH of urine, making it less favorable for bacterial growth . However, cranberry juice should be low in fructose because high-fructose corn syrup may increase bacterial growth . Bubble baths may irritate the urethra and increase the risk of infection . Voiding frequently (every 2 to 3 hours) prevents urinary stasis and bacterial growth .
Correct Answer is A
Explanation
The client has neutropenia, which is a low number of neutrophils, a type of white blood cell that fights infection. The client is at risk for developing infections from bacteria and fungi that are normally present in the environment. Raw fruits may contain these microorganisms and should be avoided.
Contact isolation is not necessary for neutropenic clients, unless they have an active infection. Applying pressure to venipuncture sites for 10 min is a standard precaution for all clients, not specific to neutropenic clients. Moving the client to a negative pressure room is indicated for clients with airborne infections, not neutropenic clients.
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