A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions shouldthe nurse take?

Use the injection port farthest from the IV catheter insertion site.

Occlude the IV tubing above the injection port.

Check for blood return after medication administration.

Flush the IV tubing with a heparinized solution.

Answer and Explanation

The Correct Answer is B

A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.

B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.

C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.

D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.

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Correct Answer is C

Explanation

A. Dependent edema can occur with pericarditis but does not indicate an immediate life-threatening complication.
B. A pericardial friction rub is a common finding in pericarditis and helps confirm the diagnosis but is not the priority.
C. A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) is a sign of cardiac tamponade, a life-threatening complication of pericarditis, and requires immediate intervention.
D. Substernal chest pain is expected with pericarditis and is usually relieved by sitting up and leaning forward, but it is not the most urgent concern.

A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting B. A client who had an intrauterine device (IUD) inserted yesterday and has cramping and bleeding C. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday

Correct Answer is D

Explanation

A. Weight loss while using a diaphragm is not typically an urgent concern and may be related to dieting; the client should be advised to follow up with her primary care provider for further

evaluation.

B. Cramping and bleeding are common side effects following an IUD insertion and typically do not require immediate attention unless severe or accompanied by other concerning symptoms;

the client should be advised to monitor her symptoms and follow up if they worsen.

C. Breakthrough bleeding is a common side effect of starting oral contraceptives and may resolve on its own after a few cycles; the client should be advised to continue taking her pills as prescribed and to follow up if the bleeding persists or worsens.

D. Shoulder pain following a laparoscopic procedure may indicate a potential complication such as referred pain from gas used during the procedure or more serious issues such as internal bleeding or organ injury; the client should be instructed to come to the clinic for further

evaluation and management.

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A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions shouldthe nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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