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 B
Explanation
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because heart rate 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed, but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
Correct Answer is ["A","B","E"]
Explanation
The correct answer is choicea, b, e.
Choice A rationale:A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.
Choice B rationale:Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.
Choice C rationale:Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.
Choice D rationale:Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.
Choice E rationale:Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.
Choice F rationale:Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.
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