A nurse is preparing to administer fentanyl 100 mcg via IV bolus to a client who is postoperative and is currently receiving 0.9% sodium chloride by continuous IV infusion. Which of the following actions should the nurse take?
Flush the port with heparin prior to administering the medication.
Inject the medication into the port closest to the client.
Pinch the tubing below the injection port prior to administration.
Administer the medication over 10 seconds.
The Correct Answer is B
A. Flush the port with heparin prior to administering the medication. Heparin is not typically used to flush the port before administering IV medications; saline is generally used for flushing.
B. Inject the medication into the port closest to the client. This ensures the medication is delivered quickly and effectively, minimizing dilution and maximizing its effect.
C. Pinch the tubing below the injection port prior to administration. Pinching the tubing can help ensure the medication goes into the client quickly but should be done only if specified by protocol.
D. Administer the medication over 10 seconds. Fentanyl should be administered slowly over 1-2 minutes to prevent rapid administration-related side effects like hypotension or respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Compile a list of the client's current medications to compare with new medications. Medication reconciliation is a key component of The Joint Commission's National Patient Safety Goals. It helps prevent medication errors by ensuring that all medications are reviewed and documented.
B. Label syringes, but not medicine cups or basins, during a procedure. All medications and solutions should be labeled to prevent medication errors, including those in syringes, medicine cups, and basins. Not labeling all items can lead to confusion and errors.
C. Use one client identifier for treatments, care, and services. Using at least two identifiers (e.g., name and date of birth) is recommended to ensure correct patient identification and reduce the risk of errors.
D. Perform a daily assessment of wounds using the Braden scale. The Braden scale is used for assessing pressure ulcer risk, not for daily wound assessment. While regular assessment of wounds is important, the Braden scale is not the correct tool for this purpose.
Correct Answer is B
Explanation
A. "Your doctor has been performing this surgery for a long time now." While this statement aims to reassure the client by emphasizing the doctor's experience, it does not address the client's feelings or encourage further discussion about their fears.
B. "Would it help you to talk more with me about how you feel?" This is a therapeutic response that encourages the client to express their feelings and concerns, showing empathy and providing an opportunity for the client to discuss their fears in more detail.
C. "I have prayed for you and everything is going to be fine." While this statement may be comforting to some, it can be inappropriate and may not address the client's specific fears or promote open communication. It also assumes the client's belief system, which might not be the same as the nurse's.
D. "Why are you afraid to have surgery all of a sudden?" This response can be perceived as dismissive and might make the client feel judged or misunderstood. It does not encourage a supportive discussion about the client's fears.
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