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. This response acknowledges the urgency of the situation and seeks clarification on the appropriate administration technique. It demonstrates readiness to follow through with the medical resident's directive while ensuring safe and effective administration.

A. This response reflects hesitation and a concern about administering a medication that the nurse did not prepare or is unfamiliar with. In a critical situation like a "code blue," timely administration of medications as directed by the medical team is crucial for patient outcomes.

C. Checking IV patency is important to ensure the medication can be administered properly. However, in a "code blue" situation where time is critical, this step might unnecessarily delay administration of the medication.

D. This response indicates willingness to follow the directive given by the medical resident. It also emphasizes the importance of documenting and obtaining proper orders after the immediate crisis has been addressed.

A. give the assistant a written warning to be placed in the personnel file. B. act as a role model and resource in identifying alternative solutions. C. perform the task for the assistant so the assistant is not embarrassed. D. give the assistant a second task so that another opportunity to succeed is provided.

Correct Answer is A

Explanation

A. Giving a written warning is a serious disciplinary action that should only be considered after other steps to support and assist the assistant have been taken. It does not promote a supportive or constructive approach to resolving the issue.

B. This option involves the nurse providing guidance and support to the assistant. By acting as a role model, the nurse can demonstrate the correct way to approach the task and provide alternative solutions or techniques. This approach encourages learning and professional development for the assistant.

C. While this may temporarily resolve the issue, it does not address the assistant's competency or provide an opportunity for learning and growth. It may also undermine the assistant's confidence and independence in performing the task.

D. While providing another task might offer another chance for success, it does not directly address the current difficulty with the delegated task. The nurse should focus on addressing the specific challenge at hand before assigning additional tasks.

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

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