The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse?
1. Resetting the pump to resume infusion
2. Discontinuing the client's IV access and restarting in a different area
3. Assessing the client's IV site and the tubing for kinks or closed roller clamps
4. Asking the client if the pump has been tampered with in any way
Correct Answer: 3
The nurse should assess the IV site because an infiltrated IV, or a site that is proximal to a joint, can impede infusion. If the IV site appears to be within normal limits, the tubing should be checked for any kinks, closed roller clamps, or any other impediment to infusion. Resetting the pump without performing a thorough assessment could increase the tissue damage if the site is infiltrated. The IV site should not be discontinued if it is intact, so it should be assessed before considering moving the site. Accusing the client of tampering with the pump would not be justified.
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