A nurse is caring for a patient who is receiving DSW with 20 mEq of KCL at 75 mL/hr. The provider has prescribed 1 g of ceftriaxone IV. When preparing to administer this medication by IV piggyback, which of the following data is the highest priority for the nurse to consider before administration?
The patient's vital signs<br>
The medication's compatibility with the primary IV solution
The patient's level of consciousness
The amount of IV solution in the primary bag
The Correct Answer is B
B. This is the highest priority. Before administering ceftriaxone via IV piggyback, the nurse must ensure compatibility with the primary IV solution (D5W with KCl). Certain medications can interact chemically or physically with other IV solutions or medications, leading to precipitation, inactivation, or other adverse effects. Compatibility should be verified through appropriate resources or pharmacy guidelines.
A. Vital signs provide crucial information about the patient's overall condition, but they do not directly impact the administration of the IV medication ceftriaxone. However, if there are significant changes in vital signs (e.g., fever, hypotension), these could influence the decision to administer ceftriaxone or any medication.
C. Important, but not directly related to medication administration. The patient's level of consciousness is crucial for assessing their neurological status and response to treatment, but it does not affect the administration of ceftriaxone IV piggyback specifically.
D. Important, but not the highest priority in this context. Monitoring the amount of IV solution in the primary bag is essential to ensure continuous fluid delivery and prevent interruptions in therapy.
However, for the immediate preparation and administration of ceftriaxone IV piggyback, ensuring compatibility with the primary IV solution takes precedence.
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Related Questions
Correct Answer is B
Explanation
B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.
A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.
C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.
D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.
Correct Answer is D
Explanation
D. The nurse should promptly notify the healthcare provider to discuss the allergy history and request an alternative antibiotic that is not structurally related to penicillin or cephalosporins. Examples of alternative antibiotics may include antibiotics from different classes such as macrolides or fluoroquinolones, depending on the indication and sensitivity profile.
A. Diphenhydramine (Benadryl) is an antihistamine that can help manage allergic reactions. However, it should not be used as a standalone precautionary measure for a client with a history of anaphylaxis to penicillin. Anaphylaxis is a severe allergic reaction that can lead to life-threatening symptoms such as difficulty breathing, swelling, and low blood pressure.
B. Before taking any further steps, the nurse should clarify and confirm the nature and severity of the client's allergic reaction to penicillin. Anaphylaxis is a serious allergic reaction characterized by rapid onset and potentially life-threatening symptoms. Clarifying the history ensures accurate decision- making regarding the administration of cephalexin.
C. This is not recommended without further clarification and assessment. Given the history of anaphylaxis to penicillin, there is a significant risk of cross-reactivity with cephalosporins like cephalexin. Cephalosporins have a structural similarity to penicillin and can provoke allergic reactions in individuals with penicillin allergy, including anaphylaxis.
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