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
Explanation
A high white blood cell (WBC) count is a common sign of infection and inflammation, such as pneumonia. The normal range of WBC count is 4,500 to 11,000/mm3 . Sodium, blood urea nitrogen (BUN), and hematocrit are not directly related to pneumonia and may vary depending on other factors such as hydration status, renal function, and blood loss.
Correct Answer is D
Explanation
A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.
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