A nurse is preparing to administer IV fluids to a client.
The nurse notes sparks when plugging in the IV pump.
Which of the following actions should the nurse take first?
Notify the biomedical department to fix the pump.
Obtain a replacement pump.
Label the pump with a defective equipment sticker.
Unplug the pump.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should first identify the impact of the mastectomy on the client’s body image.
This is because the client’s behavior of avoiding looking at her dressings and being tearful suggests that she may be struggling with changes to her body image after the surgery.
By identifying and addressing this issue, the nurse can provide appropriate emotional support and interventions to help the client cope with these changes.
Choice A is not the first action the nurse should take because referring the client to a breast cancer support group may be helpful, but it is not addressing the immediate concern of the client’s emotional state.
Choice C is not the first action because encouraging the client to assist with her dressing changes may be premature if she is still struggling emotionally with her body image.
Choice D is not the first action because providing the client with a mirror to look at her mastectomy incisions may be overwhelming for her if she is not yet ready to confront her changed appearance.
Correct Answer is B
Explanation
The nurse’s entry “New dressing applied as prescribed; no drainage on old dressing” demonstrates correct documentation because it includes specific details about the wound and the dressing change.
Choice A is wrong because it does not provide specific details about the wound or the dressing change.
Choice C is wrong because it includes subjective language (“seems” and “does not appear”) rather than objective observations.
Choice D is wrong because it only documents medication administration and does not provide any information about the wound or the dressing change.
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