A nurse is planning care for a female client who has an indwelling urinary catheter.

Which of the following actions should the nurse include in the plan?

The correct answer is d. Unplug the pump.

Rationale for Choice A:

• While notifying the biomedical department to fix the pump is important,it is not the immediate priority in this situation.The first step is to ensure patient and staff safety by removing the potential electrical hazard.
• Delaying the removal of the sparking pump could lead to electrical shock,fire,or other serious consequences.
• Biomedical staff can be notified after the immediate safety risk has been addressed.

Rationale for Choice B:

• Obtaining a replacement pump is necessary to continue the client's IV therapy,but it is not the first action the nurse should take.
• The priority is to eliminate the electrical hazard posed by the sparking pump.
• Once the faulty pump is unplugged and safety is ensured,the nurse can then proceed to obtain a replacement pump.

Rationale for Choice C:

• Labeling the pump with a defective equipment sticker is important to prevent others from using it,but it does not address the immediate safety risk.
• The priority is to disconnect the pump from the power source to eliminate the risk of electrical shock or fire.
• Labeling can be done after the pump has been unplugged and the situation has been assessed.

Rationale for Choice D:

• Unplugging the pump is the correct first action because it immediately removes the electrical hazard,preventing potential harm to the patient,staff,or equipment.
• This action prioritizes safety and mitigates the risk of electrical shock,burns,fire,or other serious consequences.
• It is essential to act quickly and decisively in such situations to ensure a safe environment for everyone involved.

This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.

Choice Cis wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice Dis wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.