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 C
Explanation
Choice A rationale:
Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.
Choice B rationale:
Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.
Choice C rationale:
Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.
Choice D rationale:
Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.
Correct Answer is A
Explanation
Choice A rationale:
Levalbuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Therefore, a decrease in wheezing is a therapeutic effect of the medication, making this the correct choice.
Choice B rationale:
While levalbuterol can cause an increase in respiratory rate as a side effect, it is not considered a therapeutic effect of the medication. The primary goal of levalbuterol is to improve breathing by relaxing the muscles of the airways, not to increase respiratory rate.
Choice C rationale:
Levalbuterol does not directly affect nausea. It is primarily used to treat conditions related to breathing such as asthma and chronic obstructive pulmonary disease.
Choice D rationale:
An increased heart rate is a potential side effect of levalbuterol, not a therapeutic effect.
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