While preparing a medication to be delivered by IV Push, a nurse verifies which of the following additional rights?
Right speed, Right dilution, and Right IV site.
Right volume, Right patient history, and Right equipment.
Right manufacturer, Right temperature, and Right storage.
Right nursing unit, Right physician, and Right pharmacy.
The Correct Answer is A
Choice A rationale
When administering a medication via IV push, the nurse must move beyond the standard five rights to ensure patient safety. Right speed is vital because pushing too fast can cause speed shock or toxicity. Right dilution is essential as many concentrated medications are caustic to veins or require specific volumes to be effective. Right IV site ensures the catheter is patent and in a vein large enough to handle the drug without causing infiltration or local tissue necrosis.
Choice B rationale
While volume, patient history, and equipment are important components of general nursing care, they are not the specific supplemental "rights" traditionally taught for the technical execution of an IV push. Volume is usually inherent in the "right dose," and equipment is a prerequisite for any procedure. The safety focus of IV push specifically targets the immediate physiological impact of the drug entering the central circulation, which is why speed and dilution are much more critical technical considerations.
Choice C rationale
The manufacturer, temperature, and storage are related to pharmacy logistics and medication stability. While the nurse should ensure a medication is not expired and has been stored correctly, these are not the secondary rights checked during the actual bedside preparation and delivery of an IV push. These factors are considered earlier in the chain of medication administration. The clinical priority at the bedside focuses on how the drug is introduced to the patient's bloodstream and vascular integrity.
Choice D rationale
Identifying the nursing unit, physician, and pharmacy is more related to administrative and documentation tasks than the clinical safety of a medication bolus. The safety rights for IV push are designed to prevent immediate adverse reactions like cardiac arrest, respiratory depression, or vein damage. Checking the physician or pharmacy name does not protect the patient from the pharmacological effects of a drug delivered at the wrong rate or in an inappropriate concentration through a peripheral or central line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Following resuscitation from cardiac arrest, assessing the neurological status by checking the ability to follow commands is the priority. This determines the presence of anoxic brain injury and guides the decision for targeted temperature management. If a patient is unable to follow commands, induced hypothermia is indicated to protect cerebral function. This assessment takes precedence as it dictates immediate, time sensitive neuroprotective interventions that significantly impact the long term functional recovery and survival of the patient.
Choice B rationale
Assessing for chest pain is important in identifying an acute myocardial infarction as the underlying cause of the arrest. However, many post arrest patients are intubated, sedated, or have altered consciousness, making subjective pain reports unreliable. While an electrocardiogram would be performed to check for ST segment elevation, the immediate physiological priority post transfer is neurological assessment to determine the need for therapeutic hypothermia, which must be initiated rapidly to be effective for brain preservation.
Choice C rationale
Auscultating breath sounds is a vital part of the secondary assessment to ensure proper endotracheal tube placement and bilateral lung expansion. While airway and breathing are fundamental, in the immediate seconds following ICU transfer after successful resuscitation, the decision tree pivots toward neurological protection. Ensuring the ventilator is functioning is routine, but the specific ICU priority for "best outcome" centers on identifying candidates for specialized protocols like cooling to mitigate reperfusion injury in the brain.
Choice D rationale
Signs of shock, such as cool, clammy skin or delayed capillary refill, indicate poor systemic perfusion and low cardiac output. Hemodynamic monitoring via blood pressure and central venous pressure is standard in the post arrest period. However, hemodynamic stabilization usually occurs during the initial resuscitation phase. Once in the ICU, the focus shifts to the subtle assessment of neurologic recovery to determine if the patient requires advanced neuroprotective bundles to prevent permanent cognitive and motor deficits.
Correct Answer is A
Explanation
Choice A rationale
Preload refers to the degree of stretch of the cardiac myocytes at the end of diastole, which is directly related to the volume of blood in the ventricles. In a patient with significant fluid loss from vomiting, diarrhea, and gastrointestinal bleeding, the intravascular volume is severely depleted. This leads to decreased venous return and low preload. Administering a fluid bolus increases the circulating volume, thereby improving preload and subsequent cardiac output.
Choice B rationale
Afterload represents the resistance the heart must pump against to eject blood into the systemic circulation. While systemic vascular resistance may increase as a compensatory mechanism in hypovolemia, a fluid bolus is not primarily intended to decrease afterload. In fact, increasing volume does not directly lower the resistance of the vessels. The primary goal in a bleeding and dehydrated patient is to restore the volume that contributes to the initial filling of the heart.
Choice C rationale
Increased preload is the desired result of the fluid bolus, not the underlying issue being treated. The patient currently suffers from a lack of volume, so their preload is low. If the preload were already increased, as seen in fluid overload or congestive heart failure, a fluid bolus would be contraindicated as it would worsen pulmonary edema and cardiac strain. The clinician uses the pulmonary artery catheter to confirm that low pressures indicate a need for volume.
Choice D rationale
Increased afterload occurs when the blood vessels are constricted, making it harder for the heart to pump. This is common in hypertensive crises or as a late response to shock. However, this patient has lost fluids and blood, which naturally points to a volume deficit. Treating increased afterload would involve vasodilators, not a fluid bolus. The clinical history of gastrointestinal loss clearly identifies a volume deficit as the primary pathological state requiring immediate fluid resuscitation.
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