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
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Correct Answer is B
Explanation
The nurse should instruct the clients to limit engaging in sport activities that can cause bruising, as radiation therapy can cause thrombocytopenia and increase the risk of bleeding. The nurse should also encourage the clients to increase their fluid intake, eat a balanced diet that includes fresh fruits and vegetables, and protect their skin from sun exposure. The nurse should not advise the clients to limit socializing in large crowds, unless they have a low white blood cell count and are at risk of infection.
Correct Answer is C
Explanation
An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.
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