Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
Heparin in Normal Saline prescribed for deep vein thrombosis.
Magnesium in Normal Saline prescribed for hypomagnesemia.
Regular insulin in Normal Saline prescribed for ketoacidosis.
The Correct Answer is A
Choice A reason: Ceftriaxone is an antibiotic that can be given by gravity infusion without an IV pump, as long as the nurse monitors the flow rate and adjusts the roller clamp as needed. The dose and duration of ceftriaxone are usually fixed and not affected by minor fluctuations in the infusion rate.
Choice B reason: Heparin is an anticoagulant that requires a precise and constant infusion rate to prevent bleeding or clotting complications. An IV pump is essential to deliver heparin safely and accurately.
Choice C reason: Magnesium is an electrolyte that can cause serious adverse effects such as cardiac arrhythmias,
respiratory depression, and muscle weakness if infused too rapidly or too slowly. An IV pump is necessary to control the infusion rate and prevent magnesium toxicity or deficiency.
Choice D reason: Regular insulin is a hormone that regulates blood glucose levels and requires careful titration based on frequent blood glucose monitoring. An IV pump is required to deliver insulin at a consistent and adjustable rate to avoid hypoglycemia or hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This client has signs of dehydration and fluid volume deficit, which can lead to shock, a life-threatening condition that occurs when the body's organs are not receiving enough blood flow. The nurse should monitor the client's vital signs, urine output, skin color, and level of consciousness, and report any changes to the physician.
Choice B reason: Initiating enteric precaution procedures is important to prevent the spread of infection, as vomiting and diarrhea may be caused by a contagious pathogen. However, this is not the most important action for the nurse to implement, as it does not address the client's immediate risk of shock.
Choice C reason: Reducing light, noise and temperature may help the client feel more comfortable and reduce nausea, but it is not the most important action for the nurse to implement, as it does not address the client's fluid volume deficit and potential shock.
Choice D reason: Encouraging electrolyte supplements may help replenish the electrolytes lost through vomiting and diarrhea, but it is not the most important action for the nurse to implement, as it may not be enough to restore the fluid balance and prevent shock. The client may need intravenous fluids and medications to correct the dehydration and hypotension.
Correct Answer is A
Explanation
Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.
Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.
Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.
Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.
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