The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Turn off the IV solution and gently flush the line with 3 mL of saline flush solution.

Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution.

Notify the physician

Check for kinking of the tubing or a closed clamp.

Answer and Explanation

The Correct Answer is D

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

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Correct Answer is A

Explanation

A. A patient who lost 2 liters of blood during surgery: This is the most acute and severe form of hypovolemia due to significant blood loss, requiring immediate fluid replacement and hemodynamic monitoring.

B. A patient who received 6 liters of IV fluid: This patient is at risk for hypervolemia, not hypovolemia, due to fluid overload.

C. A patient with UTI on PO meds: While dehydration may occur, it is typically mild and does not cause hypovolemia.

D. A patient with congestive heart failure: CHF usually leads to fluid retention, making hypovolemia unlikely unless there are other complicating factors.

A. Hematoma B. Phlebitis C. Speed Shock D. Thrombosis

Correct Answer is B

Explanation

A. Hematoma: A hematoma typically results from bleeding into the tissue, causing swelling and bruising at the infusion site, but it doesn't usually cause warmth or pain in the same way as phlebitis.

B. Phlebitis: Phlebitis is inflammation of the vein, commonly caused by an IV catheter or medication, and it often presents with redness, warmth, pain, and swelling at the infusion site. It is the most likely complication here.

C. Speed Shock: Speed shock occurs when a medication or fluid is administered too rapidly, causing symptoms such as dizziness, chest tightness, and hypotension, not localized symptoms like redness and pain at the infusion site.

D. Thrombosis: Thrombosis refers to the formation of a blood clot within a vein, which can cause swelling, warmth, and discomfort but would also likely involve more significant blockage and would be associated with reduced blood flow, not just localized redness and pain.

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The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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