The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:
every 5 hours
once per shift
hourly
once a day
The Correct Answer is C
C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.
A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.
B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.
D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A filter needle is used when withdrawing medication from an ampule, but it is not used to administer the injection. After withdrawal, the filter needle should be replaced with a regular IM needle for administration.
B. The ampule should be broken by snapping the neck away from the body, not by bending it to the side, to prevent injury.
C. The nurse should gently tap the top of the ampule, not the bottom, to move the solution downward before opening.
D. The correct technique is to insert the needle into the center of the ampule to withdraw medication, ensuring that the bevel remains below the fluid line to avoid drawing up air.
Correct Answer is ["50"]
Explanation
To calculate the flow rate in gtt/min, the total volume (400 mL) should be divided by the total time in minutes (8 hours x 60 minutes/hour = 480 minutes). This gives the mL/min.
Then, multiply the mL/min by the drop factor (60 gtt/mL) to get the gtt/min. So, the calculation would be (400 mL / 480 min) x 60 gtt/mL = 50 gtt/min.
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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