A nurse is preparing to administer an antibiotic via intermittent IV bolus for a client who has a continuous IV infusion.
Which of the following steps should the nurse take first?
Hang the antibiotic medication bag above the level of the primary infusion.
Wipe the connection port of the primary IV tubing with an antiseptic swab.
Check the IV site for signs of infiltration.
Connect the tubing of the medication bag to the primary tubing.
The Correct Answer is C
Choice A rationale:
Hanging the antibiotic medication bag above the level of the primary infusion is an important step in administering an antibiotic via intermittent IV bolus. However, it is not the first step. The medication bag is usually hung higher to allow the antibiotic to infuse by gravity once it’s connected.
Choice B rationale:
Wiping the connection port of the primary IV tubing with an antiseptic swab is a crucial step in preventing infection. However, this is typically done just before connecting the secondary line, not as the first step.
Choice C rationale:
Checking the IV site for signs of infiltration is indeed the first step. It’s important to ensure that the IV catheter is still properly placed in the vein and that there are no signs of infection or infiltration, which could cause complications.
Choice D rationale:
Connecting the tubing of the medication bag to the primary tubing is done after cleaning the port and before hanging the bag. It’s not the first step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Wheezing can be a sign of an allergic reaction to amoxicillin. It indicates that there may be constriction or inflammation in the airways, which can occur in an allergic reaction.
Choice B rationale:
Bradycardia, or a slower than normal heart rate, isn’t typically associated with an allergic reaction to amoxicillin.
Choice C rationale:
Polyuria, or excessive urination, isn’t typically a sign of an allergic reaction to amoxicillin.
Choice D rationale:
Bruising isn’t typically associated with an allergic reaction to amoxicillin. It could be related to other conditions or medications.
Correct Answer is D
Explanation
Choice A rationale:
Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.
Choice B rationale:
A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice C rationale:
A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice D rationale:
Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.
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