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 ["A","D"]
Explanation
A. Diarrhea is a common side effect associated with ondansetron, which is used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery.
B. Ondansetron can potentially cause changes in glucose metabolism, leading to hyperglycemia, especially in clients with diabetes mellitus. Monitoring blood glucose levels is essential during ondansetron administration, particularly in clients who are already predisposed to hyperglycemia.
D. Headache is a potential adverse effect of ondansetron. It is listed as a common side effect and should be monitored, especially in older adults who may be more sensitive to medication effects.
C. Ondansetron can affect the QT interval rather than the PR interval. It may cause QT interval prolongation, which can predispose the client to arrhythmias
Correct Answer is D,A,E,C,B
Explanation
The nurse should first stop the infusion (D) to prevent further infiltration of the vesicant solution. Next, the nurse should attach a syringe to the catheter (E) to prepare for aspiration.
Following this, the nurse should aspirate the solution from the catheter (C) to remove as much of the vesicant as possible. After aspiration, the nurse should disconnect the tubing from the catheter (A), ensuring that no additional vesicant is administered. Finally, the nurse should remove the IV catheter (B) to prevent any further exposure to the vesicant.
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