The patient has D5 1/2NS with 20 mEq KCI infusing through a peripheral IV site. The physician orders Protonix 40mg IVP daily. Which is the most appropriate action for the nurse?

Flush the primary line with saline before and after administering the Protonix

Hold the Protonix until the physician rounds

Call the physician to request an alternate route to administer the Protonix

Administer the Protonix through the primary line at the "Y" port

Answer and Explanation

The Correct Answer is A

A. Flush the primary line with saline before and after administering the Protonix: Protonix (pantoprazole) IV push can interact with certain solutions, and compatibility with potassium-containing IV fluids is limited. Flushing the line before and after ensures that the drug is delivered without mixing directly with D5 ½ NS with KCl, preventing precipitation, chemical reactions, or irritation to the vein.

B. Hold the Protonix until the physician rounds: Delaying administration unnecessarily could compromise patient care, particularly if the Protonix is ordered to prevent stress ulcers or gastrointestinal bleeding. The solution is not to withhold the medication but to follow proper IV administration precautions.

C. Call the physician to request an alternate route to administer the Protonix: While alternative routes such as a separate IV line could be used, flushing the existing line is an established and safe procedure. Calling the physician is not immediately necessary unless line access issues prevent safe administration.

D. Administer the Protonix through the primary line at the "Y" port: Administering the IVP medication directly into the primary line without flushing could allow it to mix with the D5 ½ NS with KCl, which may cause incompatibility reactions. Direct injection without flushing increases the risk of precipitation and vein irritation.

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Correct Answer is D

Explanation

A. Decorticate posturing involves flexion of the arms, wrists, and fingers with extension of the legs, indicating damage to the corticospinal tract above the brainstem. In the image, positioning 1 shows the patient with arms flexed at the elbows and wrists, hands toward the chest, and legs extended, which is characteristic of decorticate posturing. This occurs in response to noxious stimuli in patients with cortical or corticospinal tract injury.

B. This shows the decerebrate posturing involves extension and pronation of the arms and legs, indicating more severe brainstem injury. It usually occurs in people who are unconscious and unable to control their movements. It reflects serious injury to the brainstem or widespread brain dysfunction.

C. Decorticate posturing is an abnormal reflex body position that indicates severe brain injury or disruption of brain activity. Key Features include arms flexed tightly toward the chest, wrists and fingers clenched, legs extended straight and rigid as shown in image 1.

D. Decorticate posturing involves flexion of the arms, wrists, and fingers with extension of the legs, indicating damage to the corticospinal tract above the brainstem. In the image, positioning 1 shows the patient with arms flexed at the elbows and wrists, hands toward the chest, and legs extended, which is characteristic of decorticate posturing. This occurs in response to noxious stimuli in patients with cortical or corticospinal tract injury.

A. Inspiratory crackles B. Bilateral wheezing C. Increased respiratory rate D. Intercostal retractions

Correct Answer is C

Explanation

A. Inspiratory crackles: Crackles typically appear later in respiratory distress syndrome (RDS) due to alveolar collapse and fluid accumulation. Early in the syndrome, the alveoli are still partially functional, so crackles may not yet be present. Relying on this finding could delay recognition of the initial compromise.

B. Bilateral wheezing: Wheezing results from bronchospasm or airway obstruction and is more characteristic of conditions like asthma or COPD exacerbations. It is not an early sign of RDS, which primarily involves alveolar collapse, decreased surfactant, and impaired gas exchange rather than bronchial constriction.

C. Increased respiratory rate: Tachypnea is an early compensatory response to hypoxemia and carbon dioxide retention in RDS. The body attempts to maintain oxygenation and ventilation by increasing the respiratory rate before overt signs such as crackles or retractions appear, making it a key early indicator.

D. Intercostal retractions: Retractions indicate increased work of breathing and usually occur later in the progression of respiratory distress. They reflect significant respiratory muscle fatigue and impending respiratory failure rather than an initial compensatory change.

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The patient has D5 1/2NS with 20 mEq KCI infusing through a peripheral IV site. The physician orders Protonix 40mg IVP daily. Which is the most appropriate action for the nurse?

Nursing Test Bank

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