The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

plastic insertion spike.

catheter adapter (hub).

drip chamber.

Y-site injection port.

roller clamp to regulate flow.

Answer and Explanation

Correct Answer : A,B,D

A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.

B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.

D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.

C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.

E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.

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Correct Answer is B

Explanation

B. Expected outcomes are specific, measurable criteria used to determine goal achievement. These outcomes are set during the planning phase of the nursing process in collaboration with the client. During evaluation, the nurse compares the client's actual progress with these expected outcomes. This assessment helps determine whether the goals were met, partially met, or not met, which guides further nursing actions.

A. During the evaluation phase, the nurse assesses the effectiveness of these interventions in achieving the desired outcomes rather than the interventions themselves. The focus is on determining whether the interventions were appropriate, timely, and effective in meeting the client's goals.

C Definitions typically refer to the meaning or understanding of terms used in the nursing process, such as nursing diagnoses or medical conditions. They provide clarity and context to ensure accurate assessment, planning, and intervention. However, definitions themselves are not directly evaluated in the evaluation phase of the nursing process.

D. In the evaluation phase, the nurse assesses the client's response to interventions aimed at addressing these diagnoses. The focus is on determining the effectiveness of the care provided rather than evaluating the diagnoses themselves.

A. synergistic B. adverse C. therapeutic D. side

Correct Answer is D

Explanation

D. These effects are not the primary intended outcomes of the medication, but are known possible reactions that can occur in addition to the main therapeutic effect.

A. Synergistic effects refer to the combined action of two or more substances or medications that results in an effect greater than the sum of their individual effects.

B. Adverse effects are unintended and potentially harmful effects of a medication, even when the medication is used at therapeutic doses and in the correct manner.

C. Therapeutic effects are the desired and beneficial effects of a medication that contribute to treating or managing a medical condition. These effects are intended and typically guide the prescribing and administration of medications.

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The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the evaluation phase of the nursing process. The part of the client care plan that is evaluated during this phase are the

Correct Answer is B

Explanation

The nurse knows that many medications given to clients have predictable, secondary effects which may be harmful or may be beneficial. The nurse always includes these effects in client teaching.

Correct Answer is D

Explanation

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