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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.

Which of the following actions should the nurse take first?

Report the defect to the equipment maintenance staff.

Remove the device from the room.

Initiate a requisition for a replacement CPM device.

Ensure the device inspection sticker is current.

Answer and Explanation

The Correct Answer is B

The correct answer is b. Remove the device from the room.

Choice A rationale:

Reporting the defect to the equipment maintenance staff is essential, but it's not the immediate priority. The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
Delaying the removal of the device could lead to electrical shock, fire, or other serious consequences.
Therefore, removing the device from the room takes precedence over reporting the defect.

Choice B rationale:

Removing the device from the room is the most appropriate first action because it:
- Eliminates the immediate safety hazard.
- Prevents potential harm to the client and others.
- Protects the device from further damage.
- Ensures the safety of the environment.
- Demonstrates the nurse's prioritization of patient safety.

Choice C rationale:

Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
However, it's not the first action because it doesn't address the immediate safety concern.
The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.

Choice D rationale:

Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
However, it's not relevant to the immediate safety issue of the frayed cord.
The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.

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Correct Answer is C

Explanation

Choice A option

Fibrinogen level: Fibrinogen is a protein involved in the blood clotting process, but in this case, it is not appropriate because is not the primary laboratory test used to monitor warfarin therapy. Monitoring fibrinogen levels is more relevant in assessing bleeding disorders or certain medical conditions.

Choice B option

PTT (Partial Thromboplastin Time): PTT is another laboratory test used to evaluate blood clotting function, particularly the intrinsic pathway of the clotting cascade. PTT is not routinely used to monitor warfarin therapy; it is more commonly used to monitor other anticoagulant medications like heparin.

Choice C option

The nurse should plan to report the client's INR (International Normalized Ratio) to obtain a prescription for the client's daily warfarin. INR is a critical laboratory test used to monitor the effectiveness and safety of warfarin therapy.

Warfarin is an anticoagulant medication commonly prescribed to prevent and treat blood clots. It works by interfering with the body's ability to use vitamin K to form blood clots. Monitoring the INR is essential because it indicates how long it takes for the blood to clot, and it helps determine if the client's warfarin dosage needs adjustment to achieve the desired level of anticoagulation.

Choice D option

Platelet count: Platelet count is essential to assess the number of platelets in the blood, which are crucial for normal clotting. However, platelet count monitoring is not the primary focus when prescribing warfarin. It is typically used to evaluate thrombocytopenia (low platelet count) or other conditions affecting platelet function.

A. Document the client’s condition every 15 min B. Request a PRN restraint prescription for clients who are aggressive C. Attach the restraint to the bed’s side rails D. Remove the client’s restraint every

Correct Answer is A

Explanation

When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:

A) Document the client’s condition every 15 min

Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:

B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.

C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.

D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.

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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.

Which of the following actions should the nurse take first?