A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions shouldthe nurse take?
Use the injection port farthest from the IV catheter insertion site.
Occlude the IV tubing above the injection port.
Check for blood return after medication administration.
Flush the IV tubing with a heparinized solution.
The Correct Answer is B
A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.
B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.
C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.
D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.
B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.
C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.
D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.
Correct Answer is B
Explanation
A. This client's symptom of shortness of breath while ambulating indicates possible worsening heart failure, which requires prompt assessment but is not immediately life-threatening.
B. Vomiting coffee-ground emesis suggests upper gastrointestinal bleeding, which could be
indicative of a serious condition such as a gastrointestinal ulcer or tear and requires immediate assessment to determine the cause and initiate appropriate treatment.
C. While urinary retention in a client with benign prostatic hyperplasia requires attention, it is not as urgent as upper gastrointestinal bleeding.
D. Green drainage from the T-tube in a client who had an open cholecystectomy may indicate bile leakage, which requires assessment and intervention, but upper gastrointestinal bleeding takes precedence due to its potential for rapid deterioration.
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