When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Position the client's head facing away from the site.

Aspirate for the presence of a blood return.

Prepare a saline flush in a three mL syringe.

Initiate an infusion of 0.9% normal saline solution.

Answer and Explanation

The Correct Answer is B

A. Position the client's head facing away from the site: While positioning can help reduce the risk of infection or discomfort, it does not ensure that the catheter is patent or safe for medication administration.

B. Aspirate for the presence of a blood return: Confirming blood return verifies that the central venous catheter is patent and correctly positioned in the bloodstream. This is a critical safety step before administering intravenous medications to prevent extravasation or ineffective delivery.

C. Prepare a saline flush in a three mL syringe: While flushing the catheter is important for maintaining patency, the nurse must first confirm the catheter is patent by aspirating for blood return before flushing or administering medication.

D. Initiate an infusion of 0.9% normal saline solution: Starting a continuous infusion is not necessary solely for medication administration. The priority is confirming patency and safe access, after which flushing and medication administration can proceed.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Instruct to give additional dose if the baby vomits after administration: Giving an extra dose after vomiting can result in digoxin toxicity because the exact amount absorbed is uncertain. Parents should never repeat a dose without consulting the healthcare provider.

B. Demonstrate how to measure the correct amount of the oral solution: Accurate measurement is critical for safe digoxin administration, as small errors can lead to underdosing or toxicity. Using an appropriate oral syringe or dropper ensures the correct dose.

C. Notify the healthcare provider before giving digoxin if your baby is ill: Illness can affect heart rate, hydration, and electrolyte balance, which increases the risk of digoxin toxicity. Parents should contact the provider to determine whether to hold or adjust the dose.

D. Show the correct technique to obtain an apical pulse: Digoxin can slow the heart rate. Parents should learn to assess the apical pulse for a full minute and understand the parameters for withholding medication based on heart rate guidelines.

E. Administer digoxin on a strict every 12-hour schedule: Maintaining consistent timing ensures stable blood levels, improving efficacy and reducing the risk of toxicity. A strict schedule is essential for therapeutic effectiveness.

A. Refrain from sharing towels and razors with others. B. Complete full course of antibiotic therapy. C. Wash hands before and after touching open wounds including bug bites. D. Shower daily with antibacterial soap. E. Eat foods which contain protein and vitamin C

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Refrain from sharing towels and razors with others: Prevents transmission of bacteria that can enter through minor skin breaks and cause cellulitis. Maintaining personal hygiene items reduces the risk of reinfection or spreading pathogens to others.

• Complete full course of antibiotic therapy: Promotes healing by ensuring that the bacterial infection is fully eradicated. Stopping antibiotics prematurely can lead to treatment failure, recurrence, or development of resistant organisms.

• Wash hands before and after touching open wounds including bug bites: Prevents future cellulitis by reducing the likelihood of introducing bacteria to compromised skin. Proper hand hygiene is a key preventive measure for both the client and caregivers.

• Shower daily with antibacterial soap: Helps prevent future cellulitis by reducing bacterial load on the skin. Regular cleansing is particularly important in clients with diabetes or peripheral vascular disease, who are more prone to skin infections.

• Eat foods which contain protein and vitamin C: Promotes healing by supporting tissue repair and immune function. Adequate nutrition enhances wound healing, reduces recovery time, and strengthens defenses against infection.

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When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","E"]

Explanation

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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