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

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.

A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.

B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.

C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.

A. Hold the syringe at a 20° angle to the client's skin. B. Draw up 0.5 mL of purified protein derivative (PPD) from the vial. C. Place a 1 in needle on the syringe. D. Hold the skin taut at the chosen site with the nondominant hand before inserting the needle.

Correct Answer is D

Explanation

D. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.

A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.

B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.

C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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