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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The correct answer is choice CDE.
Choice A rationale:
Eating fish for dinner at least twice per week is not specifically recommended for pancreatitis patients. A low-fat diet is generally advised, but the frequency of fish consumption is not a key point in discharge teaching.
Choice B rationale:
Limiting coffee intake is not a primary focus in pancreatitis discharge instructions. While caffeine can irritate the digestive system, the emphasis is more on avoiding alcohol and fatty foods.
Choice C rationale:
Eating small, frequent meals is recommended to avoid overloading the digestive system and to help manage symptoms of pancreatitis.
Choice D rationale:
Pale bowel movements can indicate a problem with bile flow, which is not a normal expectation for pancreatitis patients. This could suggest a complication that needs medical attention.
Choice E rationale:
Dark urine can be a sign of dehydration or liver issues, which should be reported to a healthcare provider as it may indicate a complication.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
safety followed by the client’s pain.
The nurse should first address the client’s safety because it is the most basic and essential need according to Maslow’s hierarchy of needs. The client may be at risk of abuse or neglect from his adult child, as evidenced by the bruises, body odor, unclean clothes, low BMI, and submissive behavior. The nurse should assess the client for signs of physical or emotional abuse and report any suspicions to the appropriate authorities. The nurse should also provide a safe and supportive environment for the client and encourage him to express his feelings and concerns.
The nurse should then address the client’s pain because it is a physiological need that affects the client’s comfort and well-being. The client rates his pain as 8 on a 0 to 10 scale and is not moving his right arm. The nurse should assess the client’s arm for signs of injury, such as swelling, deformity, or bleeding. The nurse should also administer analgesics as prescribed and monitor the client’s response to pain relief. The nurse should also provide non-pharmacological interventions, such as ice packs, elevation, or distraction.
The other choices are less urgent than safety and pain. The client’s abrasions are superficial and do not pose a significant risk of infection or bleeding. The client’s hygiene is important but not a priority at this time. The client’s BMI indicates that he is underweight, but this is a chronic condition that requires long-term nutritional intervention. The client’s heart rate is slightly elevated but not alarming, and may be due to pain, anxiety, or dehydration.
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