A charge nurse is teaching a newly licensed nurse about administering heparin to a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. Discard the medication if it is yellow: Amphotericin B lipid complex is typically yellow in color. This is a normal characteristic of the medication, and it should not be discarded based on color. The nurse should be aware of the expected color and administer the medication as prescribed.
B. Administer the medication over 2 hr: Amphotericin B lipid complex is often administered over an extended period (usually over 2 to 6 hours) to minimize the risk of infusion-related reactions. However, if the prescription specifies an intermittent IV bolus, the nurse should follow the prescribed administration route and rate.
C. Prime the tubing with 0.9% sodium chloride (Correct Answer): Amphotericin B lipid complex can interact with dextrose-containing solutions, leading to the formation of a precipitate. Therefore, it is recommended to prime the IV tubing with 0.9% sodium chloride before administering the medication to prevent any potential interaction.
D. Use a gravity flow set: The choice of infusion set may depend on the specific institutional policies and the patient's condition. However, using a pump or a controlled infusion device is often recommended when administering medications like amphotericin B to ensure accurate infusion rates and reduce the risk of adverse reactions.

A. Assess the client for adverse reactions:
After ensuring the client's safety and well-being, the nurse can then proceed with the other necessary actions, such as determining the factors that led to the omission, filing an incident report, and reporting the missed dosage to the client's provider. However, assessing the client for any immediate adverse reactions takes precedence to address any potential harm that may have resulted from the missed medication dose.
B. Determine factors that led to the omission:
This is the correct answer. Understanding the factors that led to the omission is crucial for preventing future errors. The nurse should assess if there were any system failures, distractions, or other factors contributing to the missed dose.However, patient's safety and wellbeing comes first.
C. File an Incident report:
Filing an incident report is an important step, but it should not be the first action. The nurse needs to address the immediate situation and assess the factors contributing to the omission first.
D. Report the missed dosage to the client's provider:
Reporting the missed dosage to the provider is an important step, but it should not be the first action. The nurse needs to address the immediate situation, assess the client, and determine factors leading to the omission before reporting to the provider.