A client requires an IV antibiotic piggyback. The nurse understands that the primary IV solution with gravity flow tubing needs to be hung:
higher than the piggyback medication.
lower than the piggyback medication.
at the same height as the the piggyback bag.
lower than the IV insertion site.
The Correct Answer is A
A. Positioning the primary IV solution bag higher than the piggyback medication bag creates a pressure gradient, allowing the primary solution to infuse first. Once the primary solution has finished, the secondary piggyback medication automatically starts infusing. This setup ensures that the primary solution is fully infused before the piggyback medication begins.
B. Placing the primary IV solution bag lower than the piggyback medication bag is not the standard practice. This setup would create a pressure gradient that could result in the piggyback medication infusing before the primary solution, which is not desirable. It could lead to incomplete infusion of the primary solution and compromise the effectiveness of the treatment.
C. Positioning the primary IV solution bag at the same height as the piggyback bag does not create a pressure gradient for sequential infusion. As a result, both solutions would flow at the same rate, and it would be challenging to control the order of infusion. This setup is not appropriate for administering IV antibiotics via piggyback because it does not ensure the proper sequence of infusion.
D. The height of the IV solution relative to the insertion site is essential for proper infusion and preventing complications such as infiltration or phlebitis. Ideally, the IV solution should be hung at a height that allows for a gentle flow of fluid into the vein without causing excessive pressure or backflow. Placing the IV solution lower than the insertion site helps facilitate gravity-assisted flow into the vein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vomiting results in loss of hydrochloric acid (HCl) from the stomach, leading to a loss of chloride ions (Cl-) and hydrogen ions (H+) from the body. This loss of hydrogen ions can result in an accumulation of bicarbonate ions (HCO3-) relative to hydrogen ions, leading to metabolic alkalosis. Therefore, this client is at risk for developing metabolic alkalosis due to prolonged vomiting.
B. Client who has had diarrhea for the past 24 hours: Diarrhea leads to loss of bicarbonate ions (HCO3-) from the body along with fluid and electrolytes. However, metabolic alkalosis is less likely to occur with diarrhea alone because the loss of bicarbonate ions is usually balanced by the loss of chloride ions (Cl-) and hydrogen ions (H+). Therefore, while diarrhea can lead to metabolic acidosis in some cases, it is less likely to cause metabolic alkalosis.
C. Client who has overdosed on heroin: Heroin overdose is not directly associated with metabolic alkalosis. In the context of heroin overdose, respiratory depression leading to respiratory acidosis is a more immediate concern. Therefore, this client is not at risk for developing metabolic alkalosis due to heroin overdose.
D. Client who is admitted with an asthma exacerbation: Asthma exacerbation can lead to respiratory alkalosis due to hyperventilation and excessive elimination of carbon dioxide (CO2) from the body. However, metabolic alkalosis is not a typical consequence of asthma exacerbation alone. Therefore, while this client may experience respiratory alkalosis, they are not at risk for developing metabolic alkalosis solely due to asthma exacerbation.
Correct Answer is ["B","C","D"]
Explanation
B. Increased mental acuity, or heightened alertness and cognitive function, is a characteristic response during the alarm stage of GAS. The body's stress response enhances mental focus and perception to help the individual recognize and respond to the stressor effectively.
C. During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the release of adrenaline (epinephrine) and norepinephrine. These hormones stimulate the kidneys to conserve water and sodium, leading to decreased urine output and increased urine retention. Therefore, increased urine retention is an expected physiologic manifestation in the alarm stage.
D. During the alarm stage, the sympathetic nervous system activation leads to bronchodilation, allowing for increased airflow to the lungs. This facilitates improved oxygenation of the blood and enhances the individual's ability to respond to the stressor by increasing oxygen delivery to tissues.
A. During the alarm stage of GAS, the body initiates the fight-or-flight response, which leads to the release of stress hormones such as cortisol and adrenaline. These hormones increase blood glucose levels through processes like glycogenolysis and gluconeogenesis to provide energy for the body to respond to the stressor. Therefore, decreased blood glucose is not an expected manifestation in the alarm stage.
E. Decreased pupil size: During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the dilation of pupils (mydriasis). This allows for improved visual acuity and peripheral vision, enhancing the individual's ability to detect potential threats or stimuli in the environment.
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