A nurse is teaching a client about the purpose of flushing their IV site before and after medication administration. Which of the following information should the nurse include in the teaching?
It maintains sterile technique.
It ensures the IV line is clear of air before administration. after the procedure."
It verifies the IV line is working properly.
It minimizes the risk for medication errors.
The Correct Answer is C
A. While sterile technique is important during IV care, flushing the IV is not primarily for maintaining sterility.
B. Flushing can help clear air, but its main purpose is not air removal.
C. Flushing the IV line before and after medication administration helps verify patency (that the line is working properly) and ensures that the entire medication dose is delivered.
D. Flushing can help reduce medication interactions, but it is not specifically a method to minimize medication errors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Raise the drainage bag above the level of the client's abdomen: The drainage bag should be kept below the level of the abdomen to promote gravity drainage. Raising it can impede flow and increase the risk of infection or backflow.
B. Elevate the client to the high-Fowler's position: This helps enhance drainage by using gravity and decreasing abdominal pressure on the catheter.
C. Measure the amount of the dialysate outflow: This allows the nurse to assess for fluid retention and monitor the effectiveness of dialysis.
D. Monitor the access site for drainage: Observing the site for signs of leakage, infection, or obstruction is essential when outflow decreases.
E. Reposition the client onto the other side: Repositioning can help resolve catheter tip obstruction or shifting of internal organs that may be blocking outflow.
Correct Answer is ["C","D"]
Explanation
A. Capillary refill: Normal (<3 seconds). Not an emergency and does not require immediate follow-up.
B. Blood pressure: Stable: 98/64 → 104/70 mm Hg. No signs of shock or hemodynamic instability.
C. Potassium: K+ 7.1 mEq/L is critical, life-threatening hyperkalemia. This level can quickly progress to ventricular fibrillation or asystole. Requires immediate emergency treatment, such as IV calcium gluconate (stabilizes cardiac membrane), IV regular insulin + dextrose, and Kayexalate, diuretics (if appropriate), or dialysis
D. ECG: ECG shows peaked T waves and widened QRS, which are hallmark signs of impending lethal arrhythmia from hyperkalemia. Worsening QRS widening can lead to ventricular tachycardia which can progress to ventricular fibrillation and cardiac arrest. Requires urgent intervention immediately.
E. Oxygen saturation: Normal at 97% on room air. No respiratory distress.
F. Breath sounds: Clear bilaterally. No evidence of pulmonary compromise. Not a priority compared to life-threatening hyperkalemia.
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