A non-critical care nurse is part of the team in a "code blue resuscitation effort. The medical resident hands the nurse an unlabeled syringe and says. Give this to the client IV push STAT Whet response by the nurse appropriate in this emergency situation

"I will not give this substance because i did not prepare

“Since it is an emergency, how fast should I push this medication?

“I need to flush the saline lock first to make sure the IV is patent

"I will give it, but please write the order as soon as you're finished here"

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.

A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.

B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.

C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.

A. flush the catheter with normal saline prior to and after medications. B. secure the IV catheter to the extremity. C. assess IV site frequently throughout the shift. D. prevent contamination during the catheter insertion.

Correct Answer is C

Explanation

C. Regular assessment of the IV site is crucial to detect early signs of infiltration. Signs of infiltration include swelling, coolness, pain, or blanching around the insertion site. Assessing the site allows nurses to intervene promptly if infiltration occurs, preventing further complications such as tissue damage or fluid overload.

A. Flushing the IV catheter with normal saline helps to maintain patency and prevent blockage of the catheter. It also ensures that medications are effectively delivered into the bloodstream. While this action is important for maintaining the function of the IV catheter, it primarily addresses patency rather than preventing infiltration directly.

B. Securing the IV catheter to the extremity with a securement device (such as tape or a transparent dressing) helps prevent accidental dislodgement or movement of the catheter. This reduces the risk of

mechanical irritation at the insertion site, which can contribute to infiltration. Proper securement also ensures that the catheter remains in place during movement or patient activities.

D. Proper technique during catheter insertion helps reduce the risk of infection and subsequent complications, but it also indirectly contributes to preventing infiltration. Contamination during insertion can lead to inflammation or infection at the site, which may increase the risk of infiltration due to compromised tissue integrity.

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A non-critical care nurse is part of the team in a "code blue resuscitation effort. The medical resident hands the nurse an unlabeled syringe and says. Give this to the client IV push STAT Whet response by the nurse appropriate in this emergency situation

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse takes a client's temperature and gets an unexpected result. Which site would provide the most accurate temperature reading?

Correct Answer is D

Explanation

The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

Correct Answer is C

Explanation

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