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

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

B. Potassium level: The normal potassium range is 3.5 to 5 mEq/L. The client's potassium level of 5.0 mEq/L is at the upper end of the normal range. While it is within the normal range, it is important to monitor it closely since elevated potassium levels can lead to cardiac dysrhythmias. Therefore, this finding indicates a need for follow-up by the nurse.

D. Urinary output: Urinary output is an important indicator of renal function and fluid balance. If the urinary output is significantly decreased or too low, it could indicate issues with kidney function or inadequate fluid intake. Monitoring urinary output is essential to assess the client's hydration status and kidney function. Therefore, this finding indicates a need for follow-up by the nurse.

Incorrect answers:

A. Blood pressure: Blood pressure is not indicated in the provided laboratory results. It is important to monitor blood pressure, but the information provided does not suggest any abnormality related to blood pressure.

C. Respiratory rate: Respiratory rate is not indicated in the provided laboratory results. It is important to monitor respiratory rate, but the information provided does not suggest any abnormality related to respiratory rate.

E. Heart rate: Heart rate is not indicated in the provided laboratory results. It is important to monitor heart rate, but the information provided does not suggest any abnormality related to heart rate.

F. Temperature: Temperature is not indicated in the provided laboratory results. It is important to monitor temperature, but the information provided does not suggest any abnormality related to temperature.

G. Oxygen saturation: Oxygen saturation is not indicated in the provided laboratory results. It is important to monitor oxygen saturation, but the information provided does not suggest any abnormality related to oxygen saturation.

H. Skin assessment: Skin assessment is not indicated in the provided laboratory results. It is important to assess the skin, but the information provided does not suggest any abnormality related to skin assessment.

A. Generalized abdominal pain B. increased heart rate C. Fever D. Cloudy effluent

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a client. Exhibits Which of the following findings indicates a need for follow-up by the nurse? Select all that apply.

Correct Answer is ["B","D"]

Explanation

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Correct Answer is D

Explanation

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