A nurse is caring for a patient who is receiving DSW with 20 mEq of KCL at 75 mL/hr. The provider has prescribed 1 g of ceftriaxone IV. When preparing to administer this medication by IV piggyback, which of the following data is the highest priority for the nurse to consider before administration?
The patient's vital signs<br>
The medication's compatibility with the primary IV solution
The patient's level of consciousness
The amount of IV solution in the primary bag
The Correct Answer is B
B. This is the highest priority. Before administering ceftriaxone via IV piggyback, the nurse must ensure compatibility with the primary IV solution (D5W with KCl). Certain medications can interact chemically or physically with other IV solutions or medications, leading to precipitation, inactivation, or other adverse effects. Compatibility should be verified through appropriate resources or pharmacy guidelines.
A. Vital signs provide crucial information about the patient's overall condition, but they do not directly impact the administration of the IV medication ceftriaxone. However, if there are significant changes in vital signs (e.g., fever, hypotension), these could influence the decision to administer ceftriaxone or any medication.
C. Important, but not directly related to medication administration. The patient's level of consciousness is crucial for assessing their neurological status and response to treatment, but it does not affect the administration of ceftriaxone IV piggyback specifically.
D. Important, but not the highest priority in this context. Monitoring the amount of IV solution in the primary bag is essential to ensure continuous fluid delivery and prevent interruptions in therapy.
However, for the immediate preparation and administration of ceftriaxone IV piggyback, ensuring compatibility with the primary IV solution takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. After administering the PPD solution intradermally, the nurse should not withdraw the needle and massage the site. Massaging can cause the PPD to disperse outside the intended area and affect the accuracy of the test result. Instead, the nurse should gently blot the site with a gauze pad if there is any bleeding, without massaging.
A. For a Mantoux tuberculin skin test, the standard technique involves injecting a small amount of tuberculin purified protein derivative (PPD) intradermally to create a wheal or bleb that is typically 6 mm in diameter. If the nurse creates a bleb significantly larger or smaller than the recommended size, it could affect the interpretation of the test result.
B. It's important to avoid visualizing the needle tip under the skin during the injection. This can lead to inaccurate placement of the PPD solution, potentially resulting in an improperly administered test.
C. Stretching the skin tightly before injection is actually a correct technique for performing a Mantoux tuberculin skin test. This helps stabilize the injection site and ensures the needle is inserted at the correct angle for an intradermal injection.
Correct Answer is A
Explanation
Recapping needles increases the risk of needlestick injuries. Needles used for arterial blood gas (ABG) specimens should never be recapped because this action significantly increases the likelihood of accidental puncture wounds.
B. Recapping needles can lead to accidental needlesticks, so it's safer to avoid this practice. Instead, needles should be immediately disposed of in a puncture-proof sharps container.
CA Recapping needles is strongly discouraged because it increases the risk of needlestick injuries. Placing needles in a regular wastebasket does not provide adequate protection from needlestick injuries and is not in line with safe disposal practices.
D. Breaking needles is hazardous and increases the risk of needlestick injuries. Needles should never be manipulated or broken before disposal. They should be placed intact in a sharps disposal container to prevent accidental exposure.
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