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:
Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or
Choice B reason:
Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.
Choice C reason:
Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.
Choice D reason:
Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.
Correct Answer is D
Explanation
Choice A Reason:
Generalized abdominal pain - Abdominal pain may be present in peritonitis, but it can develop after other signs and symptoms.
Choice B Reason:
Increased heart rate - An increased heart rate can be a response to infection, but it is not the earliest indicator of peritonitis.
Choice C Reason:
Fever - Fever can also be a sign of infection and peritonitis but may not be the earliest manifestation in all cases.
Choice D Reason:
Cloudy effluent
The earliest indication of peritonitis in a client undergoing peritoneal dialysis is often the presence of cloudy or turbid peritoneal dialysis effluent (fluid). Cloudy effluent can indicate the presence of infection or inflammation in the peritoneal cavity, which is a significant concern in peritoneal dialysis. It's crucial for clients and their partners to recognize this early sign and seek medical attention promptly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today