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?
Reposition the client's left arm.
Check the IV site for redness.
Ensure the tubing connections are secure.
Flush the IV catheter
The Correct Answer is C
Choice A Reason:
Repositioning the client's left arm is incorrect. Repositioning the arm might help prevent kinks or occlusions in the tubing, but addressing the tubing connections comes first.
Choice B Reason:
Checking the IV site for redness is incorrect. Checking for redness is important to assess for signs of infection or inflammation, but it can wait until after addressing the tubing issue.
Choice C Reason:
Ensuring the tubing connections are secure is correct. When the infusion pump alarms, the first step is to ensure that the tubing connections are secure. A loose or disconnected tubing can lead to interrupted or inadequate infusion, which could affect the client's treatment and well-being. By checking and securing the tubing connections, the nurse can address any immediate issues related to the alarm.
Choice D Reason:
Flushing the IV catheter is incorrect - Flushing the catheter might be necessary if there are blockages or if medications need to be administered, but addressing the tubing connections is the immediate priority when the infusion pump alarms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.
Choice B reason:
Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.
Choice C reason:
Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.
Choice D reason:
Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.
Correct Answer is A
Explanation
Choice A Reason:
"I should use salt sparingly while cooking. “Response A indicates the client's understanding of the dietary teaching. Using salt sparingly while cooking is consistent with a low-sodium diet. It shows that the client recognizes the importance of reducing sodium intake to adhere to the prescribed dietary restrictions.
Choice B Reason:
"I can use baking soda when I bake" - Baking soda contains sodium and is not typically recommended for someone on a low-sodium diet.
Choice C Reason:
"I should use canned instead of frozen vegetables" - Canned vegetables often contain added sodium for preservation, so choosing fresh or frozen vegetables without added salt is a better option for a low-sodium diet.
Choice D Reason:
"I can season my foods with lemon juice" - Lemon juice is a suitable alternative to adding sodium for flavour, and this statement shows the client's understanding of using low-sodium seasoning options.
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