NCLEX Practice Test

A nurse hears various alarms sounding from different client rooms. Which alarm will the nurse address first?

1. Distal occlusion alarm on an infusion pump infusing heparin

2. Low-pressure limit alarm on a ventilator

3. Monitor alarm for a low respiratory rate of 11 breaths/min

4. Occlusion alarm on a continuous enteral feeding pump

The correct answer is: Distal occlusion alarm on an infusion pump infusing heparin

Addressing the distal occlusion alarm on an infusion pump infusing heparin is crucial because this situation poses an immediate risk to the patient. Heparin is an anticoagulant medication, and its proper infusion is vital to prevent blood clots and manage conditions that require careful anticoagulation. A distal occlusion means that the flow of the medication is interrupted, potentially leading to inadequate dosing or even a sudden increase in clotting risk if the medications are not administered properly. In the context of the other alarms, while they also indicate important issues, none pose as immediate a threat as the heparin infusion concern. For instance, the low-pressure limit alarm on a ventilator indicates a potential problem with the patient's ability to breathe correctly, which is significant, but it may not require immediate intervention if the patient is stable. The monitor alarm for a low respiratory rate of 11 breaths/min alerts the nurse to potential respiratory depression, but it might not be as critical if the patient is otherwise stable or not in distress. Lastly, the occlusion alarm on a continuous enteral feeding pump can indicate a problem, but it typically does not have the same level of urgency as issues related to anticoagulant therapy. In emergency care, prioritization is