The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)
plastic insertion spike.
catheter adapter (hub).
drip chamber.
Y-site injection port.
roller clamp to regulate flow.
Correct Answer : A,B,D
A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.
B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.
D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.
C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.
E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Delirium is often reversible once the underlying cause is identified and treated (e.g., correcting electrolyte imbalances, managing infections, discontinuing medications contributing to delirium). With appropriate intervention, the mental status can improve, and the individual can return to their baseline cognitive function.
A. Dementia, on the other hand, is a chronic, progressive syndrome that primarily affects memory, thinking, behavior, and the ability to perform everyday activities. It does not typically cause acute changes in consciousness.
B. Memory impairment is a hallmark feature of dementia, especially in the early stages. In contrast, delirium primarily affects attention, awareness, and cognition acutely, with memory impairment being variable and not a defining feature.
D. Delirium develops rapidly, often over hours to days, in response to an acute medical condition, medication change, or other factors. It is characterized by a fluctuating course and can resolve once the underlying cause is managed.
Correct Answer is ["A","B","E"]
Explanation
A. This is located on the lateral side of the thigh. It is a commonly used site for infants, toddlers, and young children, as well as adults who require large-volume injections.
B. This site is located on the hip or gluteal region. It is considered one of the safest and least painful sites for intramuscular injections in adults. It is also used when the volume of medication is larger or when the dorsogluteal site is contraindicated.
E. This site is located on the upper arm, specifically the lateral aspect. It is commonly used for vaccines and medications that require smaller volumes in adults and older children.
C. There is no specific muscle called the "rectus lateralis." It seems to be a combination of the rectus femoris (a muscle in the quadriceps group of the thigh) and the vastus lateralis. However, neither "rectus lateralis" nor "rectus femoris" is commonly used as a distinct injection site in clinical practice.
D. This site is located on the buttocks. Historically, it was a commonly used site for intramuscular injections, but it has fallen out of favor due to the potential risk of injury to the sciatic nerve and superior gluteal artery.
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