When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?
Position the client's head facing away from the site.
Aspirate for the presence of a blood return.
Prepare a saline flush in a three mL syringe.
Initiate an infusion of 0.9% normal saline solution.
The Correct Answer is B
A. Position the client's head facing away from the site: While positioning can help reduce the risk of infection or discomfort, it does not ensure that the catheter is patent or safe for medication administration.
B. Aspirate for the presence of a blood return: Confirming blood return verifies that the central venous catheter is patent and correctly positioned in the bloodstream. This is a critical safety step before administering intravenous medications to prevent extravasation or ineffective delivery.
C. Prepare a saline flush in a three mL syringe: While flushing the catheter is important for maintaining patency, the nurse must first confirm the catheter is patent by aspirating for blood return before flushing or administering medication.
D. Initiate an infusion of 0.9% normal saline solution: Starting a continuous infusion is not necessary solely for medication administration. The priority is confirming patency and safe access, after which flushing and medication administration can proceed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Demonstrate to the PN how to position the client more effectively for the procedure: The nurse is responsible for ensuring correct positioning to optimize visualization and safety during a sigmoidoscopy. Providing guidance or demonstration supports safe practice and enhances the PN’s competence.
B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: While additional assistance may be helpful, it does not address whether the client is positioned correctly, which is the immediate priority for procedural safety and effectiveness.
C. Assume care of the client and assign the PN to the care of a different client: Reassigning responsibilities may delay the procedure and does not utilize the opportunity for the PN to learn proper technique. Collaboration and teaching are preferred.
D. Acknowledge that the PN has positioned the client safely and correctly: Simply acknowledging the position without verifying or guiding may result in suboptimal visualization or risk to the client. The nurse must ensure accuracy rather than assume correctness.
Correct Answer is ["200"]
Explanation
Total volume = 100 mL.
Infusion time = 30 minutes
Infusion time = 30 minutes / 60 minutes/hour
= 0.5 hours.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
