A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?

Change the secondary IV infusion set twice weekly.

Change a continuously infusing IV bag after 48 hr.

Change the primary IV infusion set every 96 hr.

Change the extension tubing once per week.

Answer and Explanation

The Correct Answer is C

A. Change the secondary IV infusion set twice weekly: Secondary IV sets, such as piggyback infusions, should generally be changed every 24 hours to reduce the risk of contamination and infection. Changing them twice weekly would not maintain proper asepsis.

B. Change a continuously infusing IV bag after 48 hr: Continuous IV bags should be replaced at least every 24 hours to prevent bacterial growth. Waiting 48 hours increases the risk of microbial contamination and bloodstream infections.

C. Change the primary IV infusion set every 96 hr: Changing the primary IV infusion set every 96 hours (4 days) aligns with standard infection-control guidelines. This interval helps maintain asepsis while minimizing the risk of IV-related infections.

D. Change the extension tubing once per week: Extension tubing connected to the IV line should be changed more frequently, typically every 72 to 96 hours, to prevent contamination. Once per week is too infrequent and increases infection risk.

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Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}

Explanation

Rationale for correct choices:
• Transfusion-associated circulatory overload: Characterized by dyspnea, cough, crackles in the lungs, jugular vein distention, and hypertension due to fluid overload during transfusion. The client’s findings of shortness of breath, cough, crackles, and distended neck veins directly align with this condition.

• Lung sounds: The presence of new crackles bilaterally along with dyspnea indicates fluid overload affecting pulmonary circulation, consistent with TACO.

Rationale for incorrect choices:

• Acute intravascular hemolytic reaction: This reaction presents with flank pain, fever, chills, and hemoglobinuria due to incompatible blood. The client shows no evidence of hematuria, fever spike, or severe back pain.

• Anaphylactic reaction: Anaphylaxis occurs rapidly, with symptoms such as bronchospasm, hypotension, urticaria, and possible shock. The client does not have a rash, hives, or hypotension, which rules this out.

• Febrile nonhemolytic reaction: Typically presents with fever, chills, and headache caused by donor WBCs. The client’s temperature is stable and no chills are reported, so this does not match.

• Sepsis transfusion reaction: This occurs when contaminated blood is transfused, leading to fever, hypotension, and rigors. The client is not hypotensive or febrile, making this less likely.

• Temperature: A temperature rise would point to a febrile or septic transfusion reaction, but the client’s temperature remained stable.

• Urticaria: Urticaria would suggest an allergic or anaphylactic reaction, which was not observed.

• Hypotension: Hypotension is seen with hemolytic or septic reactions, but this client’s blood pressure is elevated, not decreased.

• Chills: Chills are typical of febrile or hemolytic reactions, but the client did not report them.

A. "Cover your nose and mouth with a tissue when coughing." B. "If you are coughing frequently, you should wear gloves when preparing meals." C. "Stay 2 feet away from others when coughing." D. "Turn your head away when coughing."

Correct Answer is A

Explanation

A. "Cover your nose and mouth with a tissue when coughing.": Covering both the nose and mouth with a tissue prevents respiratory droplets from spreading into the environment, reducing transmission of influenza to others. Proper disposal of the tissue and hand hygiene should follow.

B. "If you are coughing frequently, you should wear gloves when preparing meals.": Gloves are not a primary measure for cough etiquette. Hand hygiene and avoiding food preparation while symptomatic are more effective in preventing the spread of influenza.

C. "Stay 2 feet away from others when coughing.": Droplet precautions for influenza recommend maintaining at least 3 feet of distance, and ideally up to 6 feet, to prevent exposure. Two feet is inadequate to protect others from respiratory droplets.

D. "Turn your head away when coughing.": Turning the head alone does not sufficiently contain respiratory secretions. Droplets can still disperse into the air, so using a tissue or the elbow crease is more effective.

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