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 D
Explanation
Choice A rationale:
Hypotension is not typically a symptom of withdrawal from diazepam. Withdrawal from diazepam, a benzodiazepine, usually results in symptoms opposite to its therapeutic effects.
Choice B rationale:
Drowsiness is not a symptom of withdrawal from diazepam. In fact, insomnia or difficulty sleeping may occur during withdrawal.
Choice C rationale:
Anorexia or loss of appetite may occur during withdrawal from some substances but it’s not typically associated with benzodiazepine withdrawal.
Choice D rationale:
Tremors are a common symptom of withdrawal from diazepam. Other symptoms can include anxiety, restlessness, irritability, and even seizures in severe cases.
Correct Answer is C
Explanation
Choice A rationale:
The first dose of the varicella vaccine is usually given when the child is between 12 to 15 months old, not after 3 years.
Choice B rationale:
Aspirin should not be given to children due to the risk of Reye’s syndrome. This syndrome is a rare but serious condition that causes swelling in the liver and brain.
Choice C rationale:
The varicella vaccine should be avoided in children who have leukemia or any other condition that weakens the immune system.
Choice D rationale:
The varicella vaccine is not contraindicated for children who are allergic to eggs. It’s some other vaccines like influenza that have this restriction.
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