Principles of Medication & Blood

parenteral nutrition

A client who requires extensive nutritional support for an extended period of time is prescribed TPN. Home teams can help clients manage TPN at home. TPN is administered through a central line or a peripherally inserted central catheter line. Clients need to be given instructions for self-care and monitoring for complications prior to being discharged home for maintenance. Blood glucose monitoring should be done regularly, and the client should be alert for fever or signs of infection at the catheter site. A rise in temperature and unexplained hyperglycemia are symptoms of sepsis. To prevent bacterial contamination, tubing should be changed every 24 hours. The signs of infection are tenderness, redness, and possible drainage around the insertion site. A nurse cares for a client who receives a discharge prescription for total parenteral nutrition (TPN) with home care. Which statement by the client requires the nurse to provide additional education? Select All That Apply "I will change the tubing used for administration at least once every other day." Tubing should be changed every 24 hours to prevent bacterial contamination. NOT: "I will contact my health care provider for redness at the catheter insertion site." This is an indication of potential infection, and the provider should be contacted. "I will perform capillary blood glucose tests according to my provider's prescription." Blood glucose monitoring should be done regularly according to provider prescription. "I will contact my provider if my temperature is higher than 100.4° F (38° C)." The provider should be notified if the temperature is above 100.4° F (38° C), as this is an indication of potential infection. "I will contact my health care provider for drainage at the catheter insertion site." Drainage at the catheter insertion site is a potential indication of infection; the provider should be notified. TPN is a hypertonic solution with a mixture of glucose, vitamins, minerals, and electrolytes. The glucose and other nutrients in TPN solution can increase bacterial growth, which increases a client's risk of developing sepsis (widespread systemic infection). The risk for sepsis can be reduced by following administration protocols, which include changing IV tubing with each new TPN container. TPN solution containers should be changed at least every 24 hours. Frequent monitoring of central infusion catheter sites and regular dressing changes of infusion sites should also be done according to hospital policy. A nurse cares for a client receiving total parenteral nutrition (TPN). Which assessment parameters does the nurse monitor closely? Temperature TPN increases the risk for sepsis. NOT: Skin turgor Although not used for hydration purposes, TPN can result in hypervolemia. Hypovolemia could be indicated by decreased skin turgor. Alertness TPN has no effect on the client's awake/alert status. Ability to swallow TPN is administered by IV route and has no effect on the ability to swallow. PPN, total parenteral nutrition (TPN), 3-in-1, and total nutrient admixture (TNA) are forms of IV nutritional support that provide glucose, amino acids, minerals, vitamins, and fat emulsions. They can be given via peripheral or central venous catheter. If the solution is less than 10% dextrose, it can be administered by peripheral IV infusion, but this is the maximum amount considered safe for peripheral veins. Any amount greater than 10% should be administered through a central venous catheter. A nurse cares for a toddler-age client who has a prescription for peripheral parenteral nutrition (PPN). The client has a peripheral IV. The nurse knows that this client prescription should have a solution with less than what percentage of dextrose? 10% 10% dextrose or less can be administered via peripheral IV infusion. NOT: 15% This percentage would need to be administered via central venous infusion. 20% This percentage would need to be administered via central venous infusion. 25% This percentage would need to be administered via central venous infusion. When the health care provider prescribes total parenteral nutrition (TPN) and lipid emulsions, the nurse should verify the solution with the prescription. The client should be weighed daily, and electrolyte and glucose levels should be monitored per facility protocol or provider prescription to monitor for electrolyte imbalance and hyperglycemia. The client's intake and output should be monitored closely. IV tubing should be changed every 24 hours or per facility protocol for prevention of infection. A nurse cares for a client receiving total nutrient admixture (TNA). Which actions does the nurse perform while the client receives the infusion? Monitor the client's glucose levels as prescribed. The client receiving total parenteral nutrition is at risk for hyperglycemia and should have glucose levels monitored per provider prescription. NOT: Contact the provider when bottle or bag is complete. The provider needs to be contacted only if there are concerns with the infusion. Replace the IV tubing each shift. The tubing for lipids and total parenteral nutrition should be replaced every 24 hours. Weigh the client once per week and record. Clients with IV nutrition are weighed daily.

Doxorubicin (Adriamycin)

Doxorubicin is always given through the side port of a running IV infusion. Unusual dosages or unfamiliar drugs should always be confirmed with the healthcare provider and pharmacist before administration as the nurse is ultimately accountable for the drug administered. Amphotericin is a systemic antifungal treatment used for cases of candidiasis. Doxorubicin is a vesicant, which may cause blistering, severe tissue injury, or necrosis if it escapes from the intended venous pathway. Vancomycin is an antibiotic that is capable of treating several bacterial infections. Dobutamine is a drug given for low blood pressure that increases the heart's ability to pump more effectively by improving the contractile force of the muscle. Each of these drugs is a vesicant with special administration and monitoring expectations. Risk factors for infiltration or extravasation related to the IV site include the type of IV used, the site used, age of site, and care of the site. Risk factors for infiltration or extravasation related to the medication include volume of drug, concentration of drug, osmolarity of infusion, vasoconstrictive potential, and cytotoxicity. Risk factors for infiltration or extravasation related to the client include age, compromised circulation, and activity level. The nurse always administers which drug through the side port of a client's running IV infusion? Doxorubicin If extravasation of doxorubicin is suspected, the drug is stopped and interventions instituted urgently to prevent tissue loss and necrosis. This chemotherapeutic agent is administered by someone certified to do so and wearing the correct personal protective equipment. Doxorubicin is administered as an IV push over approximately 5 minutes through a free-flowing IV infusion of 0.9% NS, even if using a central venous access device. This reduces the severe risk of extravasation. NOT: Amphotericin B Amphotericin B is administered only with 5% dexrose and with an in-line membrane filter. Premedication and test doses are advised to prevent severe reactions. Though it is considered a vesicant, amphotericin B is not administered through the IV tubing's side access port but on its own IV tubing or as a secondary or piggyback medication. Vancomycin Vancomycin is typically administered intermittently as a piggyback or secondary medication. It should be given through a vein of appropriate size and flushed well after administration to reduce vein irritation. For the person with small veins, this medication can sometimes be administered more slowly. Dobutamine Dobutamine is administered as a continuous intravenous infusion through its own IV tubing. It is advised to be given in a central line. Doxorubicin is a cytotoxic antibiotic used in many chemotherapy combination therapies. Precautions are based on the cytotoxic and vesicant properties of the drug and are required to protect the nurse, others in the environment, and the client. In addition to nausea and extravasation, other adverse effects associated with doxorubicin are cardiotoxicity, immunosuppression, liver toxicity, and alopecia. The nurse prepares to administer high dose doxorubicin to a client. What actions does the nurse include? Select All That Apply Use central venous access if available. Because doxorubicin is a vesicant, all effort should be made to use a central venous device for administration to reduce the risk for extravasation. Premedicate with appropriate antiemetic. High dose doxorubicin has a high emetic potential and pretreatment with an antiemetic is recommeded. Wear gloves for preparation and administration. Doxorubicin is a hazardous agent and double gloving or wearing chemotherapy-approved gloves, wearing a gown, and using closed system transfer devices (CSTDs) are required during administration per the National Institute of Occupational Safety and Health. NOT: Place ice pack over site prior to infusion. If extravasation occurs the nurse should apply an ice pack to promote vasoconstriction and prevent further dispersal of the drug. However, promoting vasoconstriction prior to administration is not recommended. Administer via slow direct IV injection. Doxorubicin is a vesicant and should always be administered via a secondary port and not directly to the intravenous site.

Intramuscular (IM) injection

Muscle is more vascular than subcutaneous tissue, so medications administered into muscle will be absorbed more rapidly. Blood flow to the region does need to be considered, as this will affect how quickly the medication is absorbed and thus able to achieve the desired effect. A nurse prepares to administer vitamin K 5 mg by IM injection to a client. The nurse understands medication absorption is affected by which factor when administered by the IM route? Area blood flow Blood flow to the area will impact the absorption rate of the medication. NOT: Amount of fatty tissue The medication is not administered into the fatty tissue, so fatty tissue is not a factor in absorption. Strength of the muscle Strength of the muscle has no impact on the absorption rate of the medication. Size of the muscle Size of the muscle has no impact on the absorption rate of the medication. Needle length is chosen based on the site of injection. Medications in an aqueous solution can be administered with a 20-25G needle. Oil-based solutions are better administered with 18-25G needles. For children clients, a shorter needle will penetrate muscle, but adult clients require a longer needle length. Recommended lengths for child clients: ventrogluteal (½ to 1 in.), vastus lateralis (⅝ to 1 in.), deltoid (½ to 1 in.). Recommended lengths for adult clients: ventrogluteal (1½ in.), vastus lateralis (⅝ to 1 in.), deltoid (1 to 1½ in.). A nurse prepares to administer ceftriaxone 250 mg by IM injection into the ventrogluteal muscle of an adult client. Which needle does the nurse choose for the injection? 25G, 1½ in. A 25G needle is an appropriate size, and 1½ in. is an appropriate recommended length for injection into the ventrogluteal muscle. NOT: 20G, ⅝ in. A 20G needle is an appropriate size, but ⅝ in. will not reach deep enough for this site in adult clients. 22G, 2 in. A 22G needle may be appropriate size due to the viscosity of the medication, but a 2-in. needle is larger than recommended for injection for most adult clients in this site. 27G, ⅜ in. A 27G needle is an appropriate size, but a ⅜-in. length is not deep enough to reach into the ventrogluteal muscle of most adult clients. IM injections deposit medication into the muscle, where it is absorbed by blood vessels within that muscle. The rate of absorption is slower than by the IV route but faster than by the subcutaneous route. IM injections should be administered at a 90-degree angle using a quick motion. A nurse administers ceftriaxone 250 mg intramuscularly (IM) into the ventrogluteal muscle of an adult client. At which angle will the nurse insert the needle? 90 degrees For IM injections, the needle is inserted at a 90-degree angle. NOT: 60 degrees 60 degrees is not an angle used for parenteral medication administrations. 45 degrees For subcutaneous injections, the needle is inserted at a 45- or 90-degree angle. 15 degrees For intradermal injections, the needle is inserted at a 15-degree angle. IM injection sites include the ventrogluteal muscle, the vastus lateralis muscle, and the deltoid muscle. The ventrogluteal muscle is considered the safest IM injection site for adults and children, and the average adult muscle can accommodate up to 3 mL of volume. The vastus lateralis muscle is commonly used for infants and toddlers, and a well-developed muscle can accommodate up to 3 mL of volume. The deltoid muscle is easy to access but can only accommodate up to 1 mL of volume. The dorsogluteal muscle is no longer recommended for use due to its close proximity to blood vessels and nerves, creating potential for injury. A nurse reviews health care provider prescriptions for a newly admitted client. The nurse prepares to administer 12 mg betamethasone IM. The nurse retrieves a vial with 30 mg / 5 mL betamethasone. Which site does the nurse prepare for administration? Ventrogluteal The ventrogluteal muscle is the ideal site for this injection volume of 2 mL. NOT: Deltoid The deltoid muscle is not appropriate for the 2 mL volume required for this dose of medication. Dorsogluteal The dorsogluteal muscle is no longer recommended as an IM injection site. Vastus lateralis The vastus lateralis muscle is the preferred site of IM injection for infants and children. The choice of IM injection site location should be based on the client's age and the size of muscle at the injection site. IM injections for infants and children should not exceed 1 mL in a single injection. The preferred site for infants is the vastus lateralis muscle, located on the anterior lateral aspect of the thigh. To locate this site, find the upper outer quadrant of the thigh, between the greater trochanter and the knee. The ventrogluteal site is preferred for adults and children because it is away from major blood vessels and nerves. Locate this site by first placing the palm of the hand over the greater trochanter and the index finger on the anterior superior iliac spine. Then point the thumb toward the groin, aim the fingers toward the head, and spread the middle finger back along the iliac crest. The site will be in the center of the triangle created by the middle and index fingers. The deltoid site should only be used for toddlers, older children, and adults, and then only for small volumes of administration. To locate this site, place three fingers below the edge of the acromion process and the thumb on the lateral arm in line with the axilla. The injection site is in the center of this triangle. A nurse receives an order for an intramuscular (IM) injection for a 9-month-old client. Which site does the nurse prepare for administration? Vastus lateralis The vastus lateralis is the preferred IM site of injection for infants. NOT: Ventrogluteal The ventrogluteal is the preferred IM site for adults and children. Dorsogluteal The dorsogluteal site is close to the sciatic nerve, and, due to potential nerve injury, is not a recommended site for injection. Deltoid The deltoid muscle is not the first choice for injections because it may not be well developed in the infant.

Abbreviations

Physician signature, client's full name, drug name and indication, dosage, route, time schedule, order date, and time should be included in all medication orders. Indication should always be included on a PRN medication order. There needs to be a time frame for how often the "as needed" medication can be administered. A "now" order is a one time order for a medication that is needed quickly but not immediately (as in a stat order). The nurse has 90 minutes to administer a "now" order. A nurse reviews health care provider (HCP) prescriptions for a client. Which prescription requires the nurse to contact the HCP? Acetaminophen 325 mg PO PRN headache This order is missing frequency of administration. NOT: Nifedipine 10 mg PO TID This order includes name of medication, dosage of medication, route of administration, and frequency of administration. Secobarbital 100 mg PO QHS This order includes name of medication, dosage of medication, route of administration, and frequency of administration. Furosemide 20 mg IV NOW This order includes name of medication, dosage of medication, route of administration, and frequency of administration. The Joint Comission has identified "do not use" abbreviations as a means of providing safe, effective, and collaborative care. Universally unacceptable abbreviations increase continuity of care and provide guidelines for all health care providers and nurses. The nurse review written prescriptions during a computer outage. Which prescription can the nurse accurately prepare for administration? Synthroid 50 mcg one tab PO daily. The abbreviations mcg (micrograms) and PO ("per os") are acceptable abbreviations, according to the Joint Commission. NOT: Docusate sodium PO 100.0 mg one tab daily. The Joint Commission's "do not use" list of abbreviations states that the use of a trailing zero (100.0) should not be used because it increases the chance of a dosing medication error. MgSO4 4 g IM x one loading dose. MgSO4 is a "do not use" abbreviation as identified by the Joint Comission. Instead, the prescription should be written out "magnesium sulfate". Lantus 50 U QHS This prescription does not indicate the correct route of the medication. Additionally, the abbreviation "U" should be written "units", "Q" should be written "every" to avoid medication errors, and ISMP recommends writing out "at bedtime" rather than using "HS". The correct way to write the order would have been: Levofloxacin 750 mg PO daily for 7 days. The Joint Commission has placed "QD" (once daily) on the "Do Not Use" list because it is often confused with "QID," which means "4 times daily." Such confusion could result in a client getting 4 times more than the intended dose, which could cause severe adverse effects up to and including death. Alhough the nurse knows that levofloxacin is not given 4 times per day, any time an order has "QD" in it, the nurse should get an order clarification before administering the medication to prevent harm. The nurse reviews provider prescriptions for a newly admitted client. The prescription is written: Levofloxacin 750 mg PO QD X1 week. The nurse prepares to remove the medication from the medication dispensing system and notes the pharmacy has entered the order as: Levofloxacin 750 mg 4 times per day for one week. Which action does the nurse take next? Contact the health care provider. The nurse should contact the health care provider to verify if the medication is to be given daily or 4 times per day. NOT: Administer the medication as soon as possible. The nurse should not administer the medication until contacting the provider for verification, as the abbreviations "QD" and "QID" are on the "do not use" list from JCAHO. Contact the pharmacy to correct the entry. The nurse might need to contact the pharmacy, but the nurse should first contact the health care provider to verify the frequency of medication administration. Ask the client what the provider told them. The nurse should contact the health care provider about the frequency of dosing and not rely on the client for such information. Documentation of medication administration must be clear and accurate, following all standards for documentation. Abbreviations are commonly used with medication orders. While all abbreviations can be problematic, the Joint Commission has identified a list of "do not use" abbreviations that are commonly mistaken. A nurse precepts a newly hired nurse and reviews written documentation after medication adminstration on assigned clients. Which entry requires the precepting nurse to provide additional education to the newly hired nurse? Select All That Apply MS 5 mg given IV for c/o abdominal pain MS is on the "do not use" list of abbreviations. KCl given orally for low potassium level Doesn't include dosage or level of potassium which requires replacement administration. Regular insulin 10.0 u given SQ for blood glucose of 180 Trailing zeros should not be used. This could be mistakenly read as 100 , resulting in an overdose for the client. Units should be used instead of "u". OK: Acetaminophen 325mg PO given for headache 4/10 Meets all standards for accurate and clear documentation. Digoxin 0.25 mg given orally per Dr. Smith Meets all standards for accurate and clear documentation. Oxytocin is prescribed in milliunits per minute, and dosing is dependent on the strength provided by the pharmacy. Most pharmacies provide 30 units of oxytocin in a 500-mL bag of solution, creating an equivalency of 1 mu/min to 1 mL/hr; drug concentration can vary. In this case, the provider has also used a banned abbreviation (cc is not acceptable; mL is used instead), so the nurse should contact the provider for prescription clarification. The nurse who works in a labor-and-delivery unit cares for a client admitted for induction of labor. The prescription for oxytocin reads: Start oxytocin at 4 cc/hr IV. Which action does the nurse take? Contact the health care provider. The health care provider needs to be contacted to verify correct dosing of the oxytocin infusion. NOT: Begin the oxytocin at 4 mL/hr as prescribed. The nurse should contact the health care provider to verify the order for two reasons: the prescription uses a "do not use" abbreviation, and oxytocin must be ordered in milliunits per minute. Call the pharmacy to clarify the prescription. The pharmacy cannot know what the health care provider intended to order. Ask another nurse to verify the prescription. Another nurse cannot provide information regarding what the health care provider may intend the client to have. Abbreviations are commonly used with medication orders. While all abbreviations can be problematic, the Joint Commission has identified a list of "do not use" abbreviations that are commonly mistaken. The "do not use" abbreviations include the following: U, IU, QOD, QD, MS, MSO4, MgSO4, a trailing zero, and the lack of a leading zero. A nursing instructor quizzes a group of nursing students regarding abbreviations used in client health records. Which abbreviations do the students identify as acceptable to use? Select All That Apply PO PO is an acceptable abbreviationand means by mouth or oral. BID BID is an acceptable abbreviation and means twice a day. NOT: QD QD is on the "do not use" list be JCAHO. It can be mistaken for QID(4 times a day) or QOD(every other day). Daily should be used instead. IU IU is on the "do not use" list by JCAHO. It can be mistaken for IV and should be written as units. MS MS is on the "do not use" list by JACHO. It should be written as morphine sulfate. The Joint Commission has placed "u" on the "Do Not Use" list of abbreviations because it is often misread as the number "0" (zero). This mistake could cause the administration of a dose 10 times greater than intended. Instead, the word "units" should be written out to prevent confusion in dosing and also prevent a severe adverse event from a medication error. An order that uses an unapproved abbreviation needs to be rewritten correctly before being administered. Note the use of "subcut" instead of "SQ" is correct to indicate subcutaneous administration. Nurses should follow facility protocol regarding double checking doses of high-alert medications with a second registered nurse. A nurse cares for a client with increasing glucose levels. The nurse reviews a new health care provider (HCP) prescription which reads: regular insulin 5u subcut before meals. Lunch will arrive in 15 minutes. Which action does the nurse take? Contact the HCP. The nurse should contact the HCP because "u" is on the "do not use" list of abbeviations and the nurse needs to verify the dose is 5 units. NOT: Administer the insulin now. Before-meal insulin should be administered when the client has the food ready to eat. Prepare the insulin and verify with another nurse. The nurse first needs to verify the order with the HCP. Check the client's glucose level by fingerstick. There is no need to check the client's glucose level, as this is not dosage based on glucose level.

Central Line

The HCP avoids placing a central line at sites with implanted devices, previous injury or deformity. Typically, the HCP can use an alternate site and successfully place a central line. Thrombocytopenia is considered a contraindication to central line placement. However, the HCP may place a central line in a client with thrombocytopenia in a emergency with extreme care. The nurse knows that central venous access device placement is contraindicated for what client? The client with advanced lung cancer and a platelet count 42,000 mm3. Thrombocytopenia, low platelet count, is a contraindication for central line placement because of the increased risk of hemorrhage. The HCP may choose to avoid the subclavian site in the client with a low platelet count (particularly with a platelet count under 50,000 mm3), since it is hard to compress a subclavian vein in the event of hemorrhage. Alternate placement sites or various types of central venous access devices (CVAD) are considered, and a platelet transfusion can be adminstered just before CVAD placement to reduce hemorrhage risk. NOT: The client in atrial fibrillation with a left chest wall internal pacemaker. The client with a pacemaker is a central line candidate. However, the health care provider (HCP) would not use the left chest wall as an insertion site. The client on hemodialysis with a left arm arteriovenous fistula. The client on hemodialysis is a central line candidate. However, the health care provider (HCP) avoids the left arm as an insertion site because of the client's fistula. The client with a urinary tract infection and white blood cell count of 23,000 mm3. Elevated white blood cell count is not a contraindication for central lines. In fact, central lines are recommended for treatment of clients with disorders causing leukocytosis, like septic shock, who often have elevated white blood cell counts. IV solutions carry a pH range of 3.5 to 6.2. Normal serum osmolarity for the adult client is 270-300 Osm/L. Isotonic IV solutions are within this range. Hypertonic solutions are greater than 300 Osm/L, and hypotonic solutions are less than 270 Osm/L. Fluids and medications with extremes of pH or osmolarity should be infused through a central line to decrease risk for vein damage that may lead to phlebitis or thrombosis. Total parenteral nutrition (TPN) has an osmolarity of greater than 1,400 Osm/L and should be infused through a central line. A client receiving TPN normally requires a central venous catheter. Peripheral venous catheters can only infuse fluids with up to 10% dextrose, greatly limiting the types of parenteral nutrition formulas that may be administered. A nurse cares for a group of clients requiring IV medication administration. Which prescription requires the nurse to verify the client has a central line in place for administration? Administer total parenteral nutrition at 85 mL/hr. Total parenteral nutrition should be administered via central line. Peripheral parenteral nutrition may be available if necessary. NOT: Titrate dobutamine 20 mcg/kg/min to maintain a blood pressure greater than 110/70 mmHg. Vasopressors can be administered through a peripheral IV. The site should be monitored for extravasation. Ensure the correct concentration is available. Central strength and peripheral strength vasopressors are different concentrations. Infuse potassium chloride 20 mEQ/100 mL IV piggyback over 2 hours. Potassium chloride can be administered through a peripheral IV. The site should be monitored for phlebitis. 10 mEq/hr of IV potassium is safely administered peripherally. Transfuse two units of packed RBCs as soon as possible. Blood products do not require administration through a central line. Placing the client either on the left side or in the Trendelenburg position will decrease the risk of an air embolus. Preferably, the nurse would use hemostats to close the line, apply a clamp to the external catheter, or attach a Luer Lock to prevent air from entering. Other techniques that can be used to reduce the risk for air embolism include asking the client to perform the Valsalva maneuver, changing the set during the expiratory cycle during spontaneous breathing, or changing during the inspiratory cycle for clients receiving pulse pressure variation therapy. A nurse cares for a client with a central venous catheter and prepares to change the infusion administration set. There is no clamp or Leur Lock on the catheter device. Which action should the nurse take? Place the client on the left side. Placing the client either in Trendelenburg position or on the left side will help to increase intrathoracic pressure and prevent air embolism. NOT: Place patient in semi-Fowler position. Semi-Fowler position is not indicated for this procedure. Place patient in high-Fowler position. High-Fowler position is not indicated for this procedure. Place the client in the right-side lying position. A right-side lying position is not indicated for this procedure.

blood transfusion

When administering blood products, the nurse should use a 20G catheter or larger to prevent hemolysis. The nurse should stay with the client for the first 15 minutes because this is when hemolytic reactions are most likely to occur. Normal saline is the only fluid compatible with blood products and should be used between units. Baseline vitals are taken just prior to initiating the transfusion to provide a means of comparison. The Centers for Disease Control recommends that each unit be completed within 4 hours of initiation. Facilities may have specific policies about changing tubing more frequently to lower the risk of infection. The nurse prepares to administer four units of packed red blood cells (PRBCs) for rapid infusion to a client with a gunshot wound and large blood-volume loss. Which actions does the nurse take? Select All That Apply Obtain a set of vital signs prior to beginning the infusion. Vital signs should be obtained prior to initiating the transfusion. Remain with the client for the first 15 minutes of the transfusion. The nurse should remain with the client for the first 15 minutes because hemolytic reactions most often occur during this time. NOT: Prime the Y-set and blood tubing with 5% dextrose in 0.45 saline (D5½NS). Normal saline is the only fluid compatible with blood products. Change the IV tubing after each unit is complete. The Centers for Disease Control recommends changing tubing and completing each unit within 4 hours of initiation. Tubing does not have to be changed after each unit. Initiate an IV line with a 22G IV catheter. For rapid infusion, the needle gauge should be 20 or larger to prevent RBC hemolysis. Acute hemolytic transfusion reactions are commonly caused by an ABO incompatibility and occur during the transfusion or within 24 hours. The client may report burning at the IV site, chills, and pain in the back and flank. Fever may be noted. Incompatible RBCs with antigens from the wrong blood group are attacked and destroyed by antibodies in the client's plasma, leading to widespread hemolysis. These antibodies activate complement, and tissue factor is released by RBC debris, which triggers the clotting cascade. Disseminated intravascular coagulation results, causing shock, acute renal failure, and even death. If a hemolytic reaction occurs, the nurse should immediately stop the transfusion and infuse normal saline with a new IV line. The nurse should then notify the health care provider. Infusing normal saline will initiate diuresis and help avoid hypotension and vascular collapse. A nurse administers packed red blood cells (PRBCs) to a client. Twenty minutes after beginning the transfusion, the client reports pain in the back, burning at the IV site, and chills. Which actions does the nurse take? Select All That Apply Notify the health care provider of the client's status. The health care provider should be notified of the client's reaction to the blood transfusion. Save the blood bag and tubing and call the blood bank. The blood bank will need to receive the blood bag and tubing. Stop the blood transfusion immediately. The blood transfusion should be stopped immediately. NOT: Decrease the blood transfusion flow rate. The blood transfusion should be discontinued when a client has an acute hemolytic transfusion reaction. Finish the transfusion and then notify the blood bank. The blood transfusion should not be completed. In the absence of signs of an acute allergic reaction (fever, back pain, etc.), the older adult client is likely experiencing fluid overload manifesting as pulmonary edema. It is never incorrect to stop the transfusion while continuing to gather data if unsure. The client is likely experiencing circulatory overload, an adverse effect of blood transfusions. Older adult clients are at higher risk for circulatory overload with rapid blood transfusion rates and with whole-blood transfusions due to compromised circulatory ability. Transfusion should be done over 2 to 4 hours per unit of blood to limit the risk of this adverse event. Other measures, such as waiting a recommended 2 hours between starting a second transfusion, administering furosemide before, after, or during the infusion, using blood that is less than one week old, and using a needle no larger than 19-gauge will also help mitigate circulatory overload. Prompt intervention is key to alleviate adverse outcomes. The nurse cares for a frail-appearing older adult client who is receiving a packed red blood cell (PRBC) transfusion. The client reports dyspnea, has a cough, and crackles are heard when the lungs are auscultated. Which actions does the nurse take to address these manifestations? Select All That Apply 27% Stop the blood transfusion. The transfusion rate should be slowed or stopped, as the client is experiencing circulatory overload. This will allow the extra fluid to be absorbed properly into the circulatory system, thereby reducing the overload. Administer oxygen per health care provider prescription. Oxygen delivery would be appropriate because circulatory overload diminishes the capacity for oxygen delivery. Notify the prescribing health care provider of the situation. The prescribing health care provider should be notified of any adverse effects or transfusion reactions to make sure they are aware of the client's change in status and to ensure no other prescriptions are needed. NOT: Administer a prescribed beta blocker antihypertensive. Administering a beta blocker antihypertensive would not effectively address circulatory overload. A diuretic would be more appropriate to promote fluid elimination and lessen circulatory volume. Place the client in the Trendelenburg position. With circulatory overload and a report of dyspnea, the client should be placed in the upright position with the legs dependent to make it easier to breathe. The Trendelenburg position consists of the client being supine, with the legs elevated and the head down. It is appropriate for a client experiencing hypotension, not for addressing circulatory overload. A blood transfusion is initiated slowly to allow for early detection of a transfusion reaction. The nurse obtains vital signs and monitors for adverse effects such as chills, fever, shortness of breath, tachycardia, tachypnea, or flank or muscle pain. The nurse stays with the client for a minimum of 15 minutes when the transfusion is initiated. If no adverse effects are seen, the infusion rate is set to the ordered rate, and the nurse continues to regularly monitor the client, including vital signs, according to facility policy. Vital signs should be taken more frequently if a transfusion reaction is anticipated. A nurse transfuses one unit of packed red blood cells (PRBCs). How long does the nurse stay with the client after beginning the transfusion? At least 15 minutes A nurse should monitor the client for the first 15 minutes after the start of a transfusion when a reaction is most likely to occur. NOT: At least one hour A nurse should monitor the client for the first 15 minutes after the start of a transfusion when a reaction is most likely to occur; additional one-on-one monitoring is only needed under special circumstances. At least five minutes A nurse should monitor the client for the first 15 minutes after the start of a transfusion when a reaction is most likely to occur. At least 30 minutes A nurse should monitor the client for the first 15 minutes after the start of a transfusion when a reaction is most likely to occur; additional one-on-one monitoring is only needed under special circumstances. Baseline vital signs provide a way of identifying changes during the transfusion that would indicate a reaction. Vital signs are taken prior to and then 15 minutes into the transfusion and according to facility protocol. The client should be instructed about signs of a transfusion reaction and notify the nurse if symptoms develop. Blood products require verification by a second registered nurse, and in some facilities, the charge nurse. The two nurses verify client and blood product compatibility in the presence of the client and use two client identifiers for client verification prior to initiating the blood transfusion. To ensure compatibility between the client and the donor blood, the client's blood needs to be screened for typing and crossmatching. Begin the transfusion slowly, at a rate of 60-120 mL/hr. Stay with the client for the first 15 minutes and assess vital signs at 15 minutes and again at 30 minutes. Most severe reactions occur in the first 15 minutes or 50 mL of the transfusion. Watch for pain near the insertion site, backache, fever, chills, itching, hives, dyspnea, or unusual reports from the client. From the time a unit of blood is spiked, the infusion should take a maximum of 4 hours. Each unit of plasma or platelets should be administered over 30 to 60 minutes maximum. A nurse cares for a client who has a prescription for a blood transfusion. Which actions does the nurse take after initiating the transfusion? Select All That Apply Assess client for symptoms of a transfusion reaction during the first 15 minutes. The nurse should remain with the client for the first 15 minutes and assess for transfusion reactions; the most severe reactions occur during this time. Maintain a slow IV rate of 60-120 mL/hr for the first 15 minutes. The infusion should be started slowly and increased after the first 15 minutes. NOT: Obtain a set of vital signs 20 minutes after the initiating the infusion. Vital signs should be obtained before infusion, 15 minutes after initiating infusion, again at 30 minutes, and every 30 minutes until infusion is complete, or per facility policy. Ensure a rate of infusion that will allow completion within 20 minutes. A unit should be transfused no faster than 30 to 60 minutes. Leave the room and instruct the client to notify if symptoms of a transfusion reaction occur. The nurse should remain with the client for the first 15 minutes and check on the client every 15 to 30 minutes during transfusion. Baseline vital signs provide a means of identifying changes during the transfusion that would indicate a reaction. Vital signs are taken prior to and 15 minutes into the transfusion and according to facility protocol. The client should be instructed about signs of a transfusion reaction so he or she can notify the nurse if symptoms develop. Blood products require verification by a second nurse, and in some facilities the charge nurse. The two nurses verify client and blood product compatibility in the presence of the client and use two client identifiers for client verification prior to initiating the blood transfusion. In the case of bar code-scanned blood products, refer to facility policy for additional required processes. A nurse prepares to administer a blood transfusion to a client with a hemoglobin of 6.5 mg/dL. Which actions does the nurse take before beginning the transfusion? Select All That Apply Verify with a second nurse the blood product and the client's compatibility. Protocol requires that two nurses verify, in the presence of the client, that the blood product is compatible with the client. Check two client identifiers with a second nurse. Protocol requires that two nurses verify the client's identity with two client identifiers. Obtain and document the client's baseline vital signs in the record. Baseline vital signs should be obtained prior to beginning the blood transfusion. Review transfusion reaction symptoms the client should report. The nurse should review with the client possible symptoms of a transfusion reaction so the client can report them. NOT: Ask the family for verification of the client's blood type and Rh factor. It is the responsibility of the nurse to monitor the client closely for signs of a transfusion reaction. When a provider prescribes a blood transfusion, the rate of transfusion is usually specified in the prescription. A unit of packed RBCs is generally transfused in 2 hours, but can be lengthened to 4 hours for clients who are at risk for cardiovascular compromise with fluid overload. An elderly client who is anemic has no need for a rapid transfusion and could be compromised if transfused too rapidly. Blood transfusions should be complete by 4 hours of initiation due to the increased risk of sepsis from bacterial contamination after the blood is exposed to room temperatures for that long. A nurse initiates a blood transfusion at 1100 for an elderly client who is anemic. The nurse sets the infusion rate to ensure the transfusion is complete by what time? 1500 The nurse should ensure the transfusion is complete by 4 hours of initiation. NOT: 1600 Blood transfusions should be complete within 4 hours of initiation. 1200 Blood transfusion rates of less than 2 hours may be too fast for clients with cardiovascular compromise. 1300 An elderly client should have a slower rate of transfusion to minimize risk for fluid overload.

subcutaneous (SC/SQ) injection

After medication administration by the subcutaneous, intradermal, or IM route, the nurse should discard of the needle in a puncture- and leak-proof receptacle to prevent injury. If the needle has a safety device, the nurse should engage the safety device immediately after injection and discard appropriately. If the needle lacks a safety device, the nurse should discard the uncapped needle. The nurse should never recap a used needle; needles are for one-time use only. A nurse completes administration of a subcutaneous injection to a client. Which action does the nurse take next? Discard the needle into a sharps container. The needle should be disposed of immediately after administration into an approved sharps container. NOT: Document the medication administration site. Documentation, depending on the facility, is done just prior to administration or after the injection apparatus is safely disposed of. Perform hand hygiene. The nurse should wash hands after discarding the needle in the appropriate container. Monitor client for side effects of medication. The client should be monitored for side effects of the medication after the needle has been disposed of. Subcutaneous injections allow for medication to be dispersed into the loose connective tissue under the dermis. This tissue does not have a rich supply of blood vessels and provides a slower absorption rate than an intramuscular injection. Heparin should be administered as a subcutaneous injection. To minimize pain for the client, administer a heparin injection on the right or left side of the abdomen, at least 2 in. from the umbilicus, where there is more adipose tissue. The site should not be massaged after administration to prevent bruising, and the site of use should be rotated frequently. A nurse educates a client who will be self-administering heparin injections at home. Which site does the nurse recommend as the best choice for administration? Lateral abdomen The left or right side of the abdomen provides greater access to adipose tissue. NOT: Medial abdomen Away from the midline of the abdomen will have greater potential for more adipose tissue. Posterior upper arm The upper arm is an acceptable site for heparin injection, but the lateral abdomen is the best site. Superior buttocks The upper buttocks is an acceptable subcutaneous injection site, but it is not recommended for heparin injections. When administering a subcutaneous injection, the nurse should use a 25G or 27G needle. A nurse prepares to administer a subcutaneous dose of heparin to a client with a deep vein thrombosis. Which needle does the nurse choose for medication administration? 25G needle A 25G needle is an appropriate choice for a subcutaneous administration. NOT: 22G needle A 22G needle is too large for a subcutaneous administration. 18G needle An 18G needle is too large for a subcutaneous administration. 20G needle A 20G needle is too large for a subcutaneous administration. Any subcutaneous site is acceptable for insulin administration, but the abdomen is the best site. Injection into the abdomen has as much as 50% more absorption than the arm. A nurse prepares to administer a morning NPH insulin dose to a client who is diabetic. Which site is the best choice for administration of the insulin? An abdominal quadrant The abdomen (any quadrant) is the best site for insulin administration. NOT: Superior buttocks The buttocks are an approved subcutaneous injection site, but they do not have the best absorption. Anterior aspect of thigh The anterior thigh is an approved subcutaneous injection site, but it does not have the best absorption. Outer aspect of upper arm The outer arm is an approved subcutaneous injection site, but it does not have the best absorption. Insulin is administered via the subcutaneous route. Subcutaneous injections deposit medication into the loose connective tissue under the dermis, and medication is absorbed more slowly than with the intramuscular and IV routes. If you can grasp 2 in. of abdominal skin, give the injection at a 90-degree angle. If you can grasp only 1 in. of abdominal skin, give the injection at a 45-degree angle. The nurse administers regular insulin subcutaneously to a client. The nurse prepares the client's outer upper arm and inserts the needle at which angle? 45 degrees For subcutaneous injections, the needle is inserted at a 45- or 90-degree angle. NOT: 30 degrees 30 degrees is not an angle used for parenteral medication administration. 60 degrees 60 degrees is not an angle used for parenteral medication administration. 15 degrees For intradermal injections, the needle is inserted at a 15-degree angle.

purified protein derivative (PPD) skin test

A PPD test is a diagnostic test for tuberculosis and is administered by intradermal injection. Intradermal injections are given into the outer layers of the dermis and are used mostly for diagnostic tests. Very little of the drug is absorbed in the systemic system. Intradermal injections should be given at an angle between 5 and 15 degrees. A nurse in a health clinic administers purified protein derivative (PPD) tests to clients from the community. At which angle does the nurse insert the needle? 15 degrees For intradermal injections, the needle is inserted at a 15-degree angle. NOT: 30 degrees 30 degrees is not an angle used for parenteral medication administrations. 60 degrees 60 degrees is not an angle used for parenteral medication administrations. 45 degrees For subcutaneous injections, the needle is inserted at a 45- or 90-degree angle. PPD or tuberculosis skin tests should be read 48 to 72 hours after administration. Any induration (raised, hardened, or blistered area) is measured perpendicular to the long axis of the forearm and recorded in millimeters. Redness is not measured. A tuberculin reaction is positive if it is greater than or equal to 15 mm. In certain high-risk groups, less than 15 mm may be considered positive. A nurse works in a community clinic and administers purified protein derivative (PPD) tests to multiple clients on Tuesday. When does the nurse instruct the clients to return to the clinic to have the results read? Select All That Apply Friday The test can be read in 48-72 hours. This is an appropriate time frame. Thursday The test can be read in 48-72 hours. This is an appropriate time frame. NOT: Wednesday Twenty-four hours is too early to read the results. Monday This is outside the window of time when the test should be read. Saturday This is outside the window of time when the test should be read. When administering an intradermal injection, the nurse should use a short 25G or 27G needle. A nurse in a health clinic administers purified protein derivative (PPD) tests to clients from the community. Which needle does the nurse choose for test administration? 25G needle A 25G needle is an appropriate choice for intradermal administration. NOT: 18G needle An 18G needle is too large for intradermal administration. 22G needle A 22G needle is too large for intradermal administration. 20G needle A 20G needle is too large for intradermal administration.

discountinue IV line

An IV line should be removed only if IV fluids or medications are no longer needed. Assessing a client's ability to take oral fluids would be the highest priority. The other choices are not part of the priority assessment before discontinuing an IV line. A nurse prepares to discontinue an IV line on a client on the first post-operative day after abdominal surgery. What action does the nurse perform before discontinuing the line? Evaluate oral intake. The client should be able to tolerate oral intake prior to discontinuing an IV line. NOT: Assess client pain. The client's level of pain may be important assessment data, but it has no bearing on removal of an IV line. Determine urinary output. The client's ability to urinate post-surgery is important but has no bearing on removal of an IV line. Clean the IV site with antiseptic. The site does not require cleansing prior to removal of the IV line.

chemotherapy

Chemotherapy agents are vesicants, which will damage tissue on direct contact. Extravasation (leakage into tissue surrounding an IV site) of a vesicant agent can result in pain and loss of tissue. The most important nursing intervention is prevention. When infusing vesicants, the nurse should confirm that the IV line is in the vein by checking for blood return. This confirms that the IV line has not infiltrated, reducing the risk of the vesicant agent being delivered into the surrounding tissues. If a vesicant agent infiltrates at an IV site, discontinue the line immediately and remove the catheter. Because chemotherapy drugs are absorbed through the skin and mucous membranes, health care workers administering these agents should use personal protective equipment to prevent contamination per facilty protocol. Prior to any administration of medication, the nurse should verify client identity using two identifiers per facility protocol. The nurse should also verify the correct medication and dose per provider prescription. A nurse administers a vesicant chemotherapeutic agent to a client. Which actions are important prior to administration? Select All That Apply Wear gloves during administration of the chemotherapeutic agent. Wearing personal protective equipment (gloves, goggles, and gown) protects the nurse from contamination from the chemotherapeutic agent, but the most important step is to verify the infusion will be into a vein. Verify blood return in the IV line before initiating infusion. The nurse should confirm placement in the vein to reduce risk of extravasation. Verify the client using two client identifiers and medication dosage and route per prescription. Verification of the client, medication, and dose should be done prior to administration of any medication. NOT: Use sterile technique when administering the chemotherapeutic agent. The nurse should ensure the IV port is cleansed, but sterile technique is not necessary. Don a gown and mask prior to entering the client's room. Personal protective equipment is donned at the time of administration, but this does not have to be done prior to entering the room. Gown, gloves, and goggles are required personal protective equipment for administration.

Meclizine (Antivert)

Elderly clients often have reduced hepatic and renal function. This may result in elevated blood levels of medications and increased side effects. This client would benefit from a decrease in dosage. Clients taking enalapril may experience hypotension, which in the elderly client may manifest as dizziness. The client should be instructed to notify the HCP for dizziness. The nurse would question a prescription for meclizine, an antihistamine prescribed for dizziness, which may keep the client from notifying the HCP when dizziness occurs, placing the client at risk for injury due to hypotension. A nurse cares for an older adult client admitted for dizziness. The health care provider (HCP) continues all home medications while hospitalized. The nurse reviews the client's record prior to discharge and contacts the HCP for clarification of which prescriptions? (See exhibit.) View Exhibits Meclizine prescription The prescription for meclizine may create a situation where the client does not seek HCP guidance and the need for adjustment of blood pressure medication to a lower dosage. NOT: Enalapril prescription The enalapril dosage has been adjusted to a total daily dose lower than the previous prescription's to decrease side effects due to blood pressure being too low. Provider follow-up Follow-up with a change in dosage of medication is appropriate as prescribed. Allowed activity Activity as tolerated is appropriate for this client.

Lipid Emulsion

Fatty acids are classified as essential or nonessential. Linoleic acid, the only essential fatty acid in humans, is a source of energy and calories. Linoleic acid and arachidonic acid are important and manufactured by the body with the presence of linoleic acid. Clients will develop a deficiency if fat intake falls below 10% of daily nutritional intake. Lipid emulsions are available as 10%, 20%, or 30% emulsions. They supply essential fatty acids to clients receiving TPN. A client deficient in linoleic acid is immunosuppressed and at risk for infection. A nurse prepares to administer a lipid emulsion to a client who requires total parenteral nutrition (TPN). Which is an included ingredient in lipid emulsion? Linoleic acid Linoleic acid is an essential fatty acid in prepared lipid emulsions. NOT: Arachidonic acid Arachidonic acid is created by the body when linoleic acid is present. Carbonic acid Carbonic acid is produced by the combination of carbon dioxide and water in the body. Lactic acid Lactic acid is formed in muscles and RBCs as the body converts food into energy.

regular and NPH insulin

If a client requires more than one type of insulin to maintain glucose control, the nurse can mix the insulins in one syringe for administration. Before mixing, the nurse should verify insulin compatibility. Regular insulin and insulin NPH are compatible, even though the former is short-acting and the latter is intermediate-acting. After verifying the dose to be administered, the nurse first gently rolls the insulin NPH vial to resuspend the insulin. After cleansing the top of the vial, the nurse injects air in the amount to be withdrawn without letting the needle tip touch the insulin. Then nurse then removes the syringe without withdrawing insulin. Next, the nurse cleanses the top of the regular insulin vial, injects air in the amount to be withdrawn, and withdraws the correct dose of regular insulin. The nurse removes all air bubbles before pulling the needle from the regular insulin vial. The nurse then injects the needle into the insulin NPH syringe and withdraws the desired dose. The combined dose should be administered within five minutes of preparation; this is because the short-acting insulin will bind with the intermediate-acting insulin, thus reducing action of the faster-acting insulin. Because insulin is a high-alert medication, the best practice is to verify each type of insulin when preparing and prior to adminstration. The nurse should follow specific facility protocol regarding documentation of second nurse verification. A nurse prepares to administer insulin isophane (NPH) 22 units and regular insulin 10 units to a client. Which actions does the nurse take prior to administering the combined dose of insulin? Select All That Apply Draw the dose of regular insulin into the syringe first. The regular insulin should be drawn into the syringe prior to the insulin NPH to prevent the regular insulin being contaminated by the insulin NPH. Verify the combined dose with a second nurse. To ensure accurate dosing and prevent client harm, the dose of insulin should be verified with a second nurse prior to administration. Inject air into the vial of insulin NPH first. The nurse should first inject air into the insulin NPH vial. NOT: Wait five minutes for the insulins to mix before administering. After the insulins are mixed, they should be administered within five minutes of preparation. Shake the insulin NPH to fully mix the solution. The insulin vial should be gently rolled to mix.

IV Infiltration

Infiltration occurs when the catheter becomes dislodged or displaced from the lumen of the vein. This can occur when an IV line is placed in a flexion area or with clients who have thin or fragile veins (such as older clients). Signs of infiltration include swelling near the site, blanching, and cool skin. The client may report mild discomfort or stinging at the site. When an IV site infiltrates, the nurse should remove the IV, assess the area and document findings, elevate the affected limb, and find an alternate location to restart the IV fluid. For isotonic or hypotonic fluid, warm compresses are generally preferred to aid absorption and promote comfort. For other types of infiltration involving significant swelling or irritating medications, the approach includes cold compresses to limit absorption and decrease inflammation. For hypertonic fluids, the nurse can apply cold to restrict contact with local tissue. The nurse cares for a client who experiences an IV infiltration from normal saline. The nurse first stops the infusion. The nurse takes which additional actions? Select All That Apply Document a description of the site. The nurse should document a description of the infiltrated site in the client's electronic health record. Remove the IV line. When a client experiences an IV infiltration, the nurse should remove the IV line. Elevate the limb affected by infiltration. The affected limb should be elevated for comfort. NOT: Apply a cold compress to the site. Cold compresses are not recommended for infiltration of isotonic fluids. Contact the health care provider. The health care provider does not need to be notified of a normal saline infiltration. The IV should be restarted. Infiltration occurs when the catheter becomes dislodged or displaced from the lumen of the vein. This can occur when an IV line is placed in a flexion area or with clients who have thin or fragile veins (for example, older clients). Signs of infiltration include swelling near the site, blanching, and cool skin. The client may report mild discomfort or stinging at the site. When an IV site infiltrates, the nurse should remove the IV, assess the area and document findings, elevate the affected limb, and find an alternate location to restart the IV fluid. For isotonic or hypotonic fluid, warm compresses are generally preferred to aid absorption and promote comfort. For other types of infiltration involving significant swelling or irritating medications, the approach includes cold compresses to limit absorption and decrease inflammation. For hypertonic fluids, the nurse can apply cold to restrict contact with local tissue. When a nurse prepares to administer an intravenous pyelogram (IVP) drug, the nurse observes swelling at the client's IV site with normal saline infusing. It feels cool and the client reports mild discomfort. The nurse takes which action? Select All That Apply Start a new IV line. After discontinuing the infiltrated line, the nurse should initiate a new IV infusion at a suitable site. Discontinue the IV line. The nurse should discontinue the IV line. NOT: Contact the health care provider. The health care provider does not need to be notified. Managing an infiltration is within the nurse's scope of practice. Check IV site for patency. The IV has inflitrated, and the nurse does not need to check for patency. Apply a cool compress to the site. A warm compress should be used for isotonic solutions to aid in distributing the fluid and easing site discomfort.

Flu Shot

Needle length is chosen based on site of injection. Medications in an aqueous solution can be administered with a 20-to-25G needle. Oil-based solutions (such as lorazepam or depo-provera) are better administered with 18-to-25G needles. For children, a shorter needle will penetrate muscle, but adult clients require a longer needle. Recommended lengths for children: ventrogluteal (½ to 1 in.), vastus lateralis (⅝ to 1 in.), and deltoid (½ to 1 in.). Recommended lengths for adult clients: ventrogluteal (1½ in.), vastus lateralis (⅝ to 1 in.), and deltoid (1 to 1½ in.). Needle length may need to be outside of these recommendations for larger or smaller individuals. A nursing student prepares to administer a flu vaccination by intramuscular (IM) injection into the deltoid muscle of an adult client. Which needle does the student choose for the injection? 22G, 1 in. A 22G needle is an appropriate size, and 1 in. is the correct length to dispense medication into the deltoid muscle. NOT: 27G, ⅝ in. A 27G needle is generally not recommended for IM injections, and ⅝ in. is not deep enough for most adult deltoid muscles. 25G, ½ in. A 25G needle is appropriate size, but ½ in. will not reach deep enough for the deltoid muscle in most adult clients. 20G, ⅜ in. A 20G needle is an appropriate size, but ⅜ in. will not reach deep enough for the deltoid muscle in adult clients.

Cleaning injection site

Prior to administering an injection, the site should be cleansed for 30 seconds with a 60-70% alcohol-based solution. The site should be allowed to dry completely prior to injection. A nurse cleanses the client's abdomen prior to an insulin injection. When does the nurse administer the injection? When completely dry After cleansing, the nurse can administer the injection when the site is completely dry. NOT: Immediately The site should be dry prior to injection. Thirty seconds after application There is no set time the nurse needs to wait. The nurse can administer the injection after the site is completely dry. Within one minute There is no set time the nurse needs to wait. The nurse can administer the injection after the site is completely dry.

Codeine Allergy

The nurse must always check the client's allergy list and ensure that the health care provider prescriptions are safe to administer. A client with a codeine allergy should not receive oxycodone but may receive ketorolac for pain relief. A client with an iodine allergy should not receive traditional contrast medium used in radiography; however, the same client can receive gadolinium contrast if renal function is normal. A nurse cares for a client with kidney stones. The nurse takes verbal prescriptions from the health care provider. Which prescription does the nurse question, based on the client's health record? (See exhibit.) View Exhibits Oxycodone 5 mg oral every 4 hours as needed for pain. The client is allergic to codeine and should be prescribed oxycodone cautiously, as a client with a true allergy to codeine may also have an allergy to oxycodone. Many clients do not have true allergies, but this requires clarification before this opioid is given. NOT: Ketorolac 30mg IV every 6 hours as needed for pain; do not exceed 120mg/day Ketorolac (Toradol) is an NSAID that may help with the client's pain if the client is allergic to codeine. Kidney, ureter, bladder radiography The KUB is an x-ray that is often used as the first diagnostic imaging to diagnose problems of the urinary system. The test does not use contrast and would be safe for the client. Renal MRI with gadolinium contrast The client is allergic to iodine and should not have traditional radiography contrast medium. However, gadolinium is an option for the client with an allergy to iodine. Gadolinium is used with caution for individuals with renal insufficiency; however, there is no indication this client has renal insufficiency.

Heparin

This is why nurses must double check heparin in most institutions. This scenario could result in a serious medication error. The prescription reads, "IV heparin bolus 4000 units stat". The label on the medication vial on hand reads, "heparin sodium 100 units/ml." A 4000 unit bolus dose should be withdrawn from a large vial, typically 10,000 units per 10ml. Sometimes the infusion pump is able to deliver this dose from an infusing bag of heparin. (Check the institution's policy on this.) Heparin concentrations of 100 units/ml are usually intended to heparin-lock an intravenous central line, like a port-a-cath. A nurse prepares a medication for the treatment of myocardial infarction and asks a second nurse to verify what is prepared. The prescription reads, "IV heparin bolus 4000 units stat". The label on the medication vial on hand reads, "heparin sodium 100 units/mL." What is the appropriate response by the second nurse? Clarify the prescription and prepare the medication again. The second nurse asks to review the original order, or prescription, with the assigned nurse. Then assists in obtaining the correct medication. NOT: Administer the drug as prepared using a 40 mL syringe. In order to do this, the nurse would need to open multiple vials - a red flag that the administration is incorrect. Very rarely should a nurse have reason to withdraw more than one or two vials for a single dose of medication. Dilute the drug with 10 mL normal saline in the syringe. Diluting the drug does not achieve the dose desired. Dilute with 250 mL 5% dextrose bag and give intravenously. A heparin bolus is delivered quickly, usually via IV push or a special bolus setting on an infusion pump. Administering an additional 250ml of fluid as a bolus can create problems for the client such as fluid overload.

Trough Level

Vancomycin levels are monitored to ensure the dose ordered is sufficient to maintain a therapeutic dose. Health care providers often prescribe serum peak and trough levels. The peak measurement provides information regarding the maximum level of medication in the client's system and is drawn 30-60 minutes after medication administration. A trough is measured during the drug's lowest level, about 30 minutes before the next dose is given. A nurse cares for a client receiving IV vancomycin. The health care provider prescribes a trough drug level. When does the nurse obtain a blood sample? Thirty minutes before the next dose administration Thirty minutes prior to administration provides the lowest level of medication in the client's system. NOT: Thirty minutes after the next dose administration Thirty minutes after the next dose administration will provide a peak level. Halfway between the next two scheduled administrations Halfway between the next two scheduled administrations does not provide for lowest level of medication in client's system. When initiating the next dose administration When initiating the next dose would allow for medication to be in the system.

Vial medication

Vials can contain single or multiple doses of a medication. Best practice is to clean the top of the vial after removing the cap to ensure sterility prior to inserting the needle. Air in an amount equal to the volume to be dispensed must be injected into the vial before fluid can be withdrawn. This is done by using a needle per facility policy (a blunt needle or a needleless system). After injecting air into the vial, the nurse should invert the vial while holding the plunger in place and then remove the medication to be administered. This prevents withdrawal of a large volume of air into the syringe instead of the medication. After obtaining the desired amount of medication, the nurse should remove all air bubbles from the syringe prior to administration to the client.

IV Fluid Therapy

When utilizing IV therapy for fluid replacement, the nurse should assess for effectiveness of therapy or for fluid overload. Clinical assessment of dehydration includes the following: concentrated/dark urine, decreased skin turgor, dry mucous membranes, thirst, weight loss, hypotension or postural hypotension, tachycardia, and weak pulses. Fluid overload may be indicated by jugular vein distention, peripheral edema, or shortness of breath. A nurse cares for a client receiving isotonic fluids intravenously at a rate of 150 mL/hour for the past 12 hours. Which assessment findings require the nurse to notify the health care provider? Select All That Apply Decreased skin turgor Decreased skin turgor is an assessment finding that may indicate dehydration. Dry mucous membranes Dry mucous membranes can be an assessment finding indicative of dehydration. Jugular vein distention Jugular vein distention is an assessment finding that may indicate fluid overload. NOT: Blood pressure of 128/72 mmHg Blood pressure of 128/72 mmHg is within normal limits and an indication of hydration. Light, yellow-colored urine Light, yellow-colored urine is an assessment finding that indicates hydration. Suppose that, during an assessment, a nurse notes an IV solution infusing that is different than the HCP prescriptions. The nurse should contact the HCP to determine if a verbal order to change the fluid was received but not entered into the client's health record. If the infusion running is incorrect per provider, the nurse should change the solution to the correct solution, document the findings and fluid change, and complete an incident report. The nurse should not discontinue the IV infusion without first contacting the HCP. The priority is to ensure the prescribed solution is infusing. A nurse reviews health care provider (HCP) prescriptions for a client with a diagnosis of pneumonia. Upon assessment, the nurse notes the client has an IV of 0.9% normal saline (NS) infusing at 75 mL/hr. Which action does the nurse take? (See exhibit.) Select All That Apply View Exhibits Contact the client's HCP. The nurse should contact the HCP to clarify the prescription for IV fluids. Complete an incident report. The nurse should complete an incident report if it is determined the incorrect IV fluids are infusing. Document the assessment in the client's chart. The assessment should be documented in the client's record. NOT: Saline lock the client's IV catheter. The nurse can leave the NS infusing or decrease to a "keep vein open" rate until the HCP can verify the correct IV fluid prescription. The solution may not be optimal or correct, but it is not harmful, and the client is supposed to be getting IV hydration continuously. Discontinue the client's IV infusion set. The IV infusion set does not have to be changed between basic fluid types. The nurse can simply remove one fluid type and replace it with the new fluid type, if indicated.

Capsule and Extended-Release (XR) medications

A capsule is a form of medication that contains powder, liquid, or oil in a hard or soft gelatin. It may be timed-release or sustained-release designed to work over a period of time. It should be administered whole to achieve the desired result. Dissolving or opening the capsule may alter its onset of action, absorption, and duration. If a client is unable to swallow a capsule, the nurse should check for other forms or routes available and contact the provider to obtain a different prescription. There are exceptions to this. For example, methylphenidate XR is a capsule that can be opened and sprinkled while maintaining its extended-release properties. A nurse cares for a client who has a prescription for oxycodone extended release. The pharmacy provides the medication in a capsule, and the client has difficulty swallowing it. Which action does the nurse take? Notify the health care provider and request a different route. The nurse should contact the provider and determine if an alternate route can be prescribed. NOT: Call the pharmacy and request an alternate route. The nurse should first check with the provider to determine if an alternate route can be utilized. Open the capsule and dissolve the contents in water. The medication is provided in extended-release capsule form. Opening the capsule will affect the rate of absorption. Insist the client swallow the medication. Insisting the client swallow the medication can negatively affect the nurse-client relationship. A capsule is a form of medication that contains powder, liquid, or oil in a hard or soft gelatin. It may be timed-release or sustained-release designed to work over a period of time. It should be administered whole to achieve the desired result. Dissolving or opening the capsule may alter its onset of action, absorption, and duration. If a client is unable to swallow a capsule, the nurse should check for other forms or routes available and contact the provider to obtain a different prescription. A nursing instructor reviews PO medication formulations with a nursing student prior to administering morning scheduled medications to assigned clients. Which statement regarding extended-release capsules by the nursing student requires additional education? Select All That Apply "If the client is unable to swallow this, I can open the capsule and dissolve it in liquid." Capsules should not be divided, opened, or crushed. There are very specific medication exceptions to this. "The client should let the capsule dissolve under the tongue and then swallow." The client should not let the capsule dissolve in the mouth prior to swallowing. NOT: "This form lets the provider decrease the frequency of medication dosing." The use of extended or sustained release capsules helps to limit the frequency of dosing of certain medications. "In this form, the medication is delivered at a slow and steady dose over time." Extended-release capsules are designed to release medication over a period of time to maintain effectiveness for longer periods of time. "The client needs to swallow the pill whole without chewing or crushing." The client should swallow the capsule whole to achieve the desired effect. Extended/sustained release or enteric coated (EC) medications have unintended consequences when crushed or otherwise altered. Other tablets can be crushed and mixed with water in order to be administered through an NG tube. Medications in liquid or suspension form can be administered via an NG tube. A nurse reviews provider prescriptions for a client whose medications are administered through a nasogastric (NG) tube. Which prescription requires the nurse to contact the health care provider? Metformin XR 1,000 mg ½ tablet, daily with dinner An extended-release tablet should not be crushed to deliver through an NG tube. NOT: Metoprolol 100 mg PO daily This tablet can be crushed to be delivered through the NG tube. Acetaminophen 325 mg / 5 mL PO q4h prn headache The liquid can be administered through the NG tube. Amoxicillin 250 mg / 5 mL PO q8h The liquid can be administered through the NG tube.

Blood compatibility

A hemolytic reaction occurs with an Rh or ABO incompatibility. O-negative is the universal donor because it does not have A or B properties, and A and B blood types do not have O antibodies. AB clients can receive both A and B blood types as long as there is an Rh compatibility. The Rhesus factor is the presence of proteins in the cell, which is what the body reacts to. Rh-negative blood can donate to Rh-positive blood of the same type because there are no proteins, but Rh-positive blood cannot donate to Rh-negative blood. Acute hemolytic transfusion reactions are commonly caused by an ABO incompatibility and occur during the transfusion or within 24 hours after. The client may report burning at the IV site, chills, and pain in the back and flank. Fever may be noted. Incompatible RBCs with antigens from the wrong blood group are attacked and destroyed by antibodies in the client's plasma, leading to widespread hemolysis. These antibodies activate complement, and tissue factor is released by RBC debris, triggering the clotting cascade. Disseminated intravascular coagulation results, causing shock, acute renal failure, and even death. Delayed hemolytic transfusion reactions occur 1-14 days after a transfusion. Donor RBCs are destroyed, but hemolysis is "delayed" while the antibodies prepare a response. The recipient's antibodies were often formed during a previous transfusion or other sensitization. During the transfusion, the level of antibody was too low to cause an acute transfusion reaction. However, when the client reencounters the antigen, the client rapidly produces more antibodies (secondary stimulation). Over the following days, the antibodies bind to the donor RBCs, which are subsequently removed from circulation by macrophages. This type of reaction is usually much less severe than acute hemolytic reactions. Anaphylaxis is a life-threatening allergic reaction that can occur after only a few milliliters of blood have been given. The client reports difficulty breathing, wheezing, and coughing. There may be nausea and vomiting, but no fever. The reaction may progress to low blood pressure, respiratory depression or arrest, and circulatory shock. Treatment includes STAT epinephrine. A nurse prepares a blood transfusion for an anemic client. Which finding requires the nurse to hold the blood transfusion for the client? Blood product is A-positive; client is AB-negative. Rh-positive blood cannot be given to Rh-negative blood. NOT: Blood product is O-negative; client is B-negative. O-negative blood is a universal donor. Blood product is A-negative; client is A-positive. Rh-negative blood can be given to Rh-positive blood with ABO compatibility. Blood product is B-positive; client is B-positive. Blood is ABO and Rh compatible.

Automated Medication Dispensing System

Automated medication dispensing systems are networked with a computerized order entry system. When prescriptions are entered into the system, they can be verified by the pharmacist and made available for retrieval by the nurse on the floor. The nurse does not have to wait for medications that are routinely stocked to be delivered to the floor from the pharmacy. New prescriptions can be administered much more quickly. A group of nurses receives orientation on a medical-surgical unit. The unit plans to implement an automated medication dispensing system. Which advantage related to this system improves client outcomes? Availability of new medications orders With an automated system, the orders can be verified by the pharmacist and entered into the system for retrieval by the nurse. NOT: Reduction of transcription errors A dispensing system is not a computerized order entry system. Reduction of calculation errors A dispensing system has no bearing on nurse calculation of dosing. Minimization of telephone-order errors A dispensing system has no bearing on the number of telephone orders.

Age-related macular degeneration (AMD)

Age-related macular degeneration (AMD) is usually of the dry form which results in gradual blockage of retinal capillaries and a deterioration of the macula area which is responsible for central vision. There are few treatments and the condition is progressive. Other assessments such as whether the client still operates a motor vehicle should be done but the focus of this question is only on diabetes self-management with insulin. A client with diabetes and moderate age-related dry macular degeneration (AMD) self-injects insulin using a syringe. The nurse includes what assessments related to blood glucose management? Select All That Apply Recent blood glucose result trends. If the client's vision has been interfering with accurately preparing and injecting insulin, the nurse would expect to see lability in results with episodes of either hypoglycemia or hyperglycemia. This information helps the nurse prioritize interventions. Client's technique using a syringe. Observing the client will assist the nurse in formulating the best plan should alternate administration methods be needed. Home supports and insurance options. Based on the assessment findings, the nurse will make suggestions to the client for safe alternatives to using syringes. Knowing the client's access to home supports and insurance coverage will influence the suggestions made. NOT: Visual acuity using a Snellen eye chart. The nurse would not need to assess the client's overall vision for this purpose. The focus is on the client's ability to safely administer insulin. Optic and oculomotor cranial nerves. Cranial nerves do not play a role in macular degeneration and would not need to be assessed in this case.

Air bubbles

Air bubbles can alter the amount of medication the client receives. Therefore, the nurse should attempt to remove all air bubbles. A nurse prepares to administer an IM injection to a client and observes a few small air bubbles in the syringe. Which is affected when the nurse fails to remove air bubbles prior to administration? Dose Air bubbles can alter the dose of medication drawn into the syringe. NOT: Absorption Air bubbles do not alter the rate of absorption of medication from the tissue. Duration Air bubbles do not alter the duration of effectiveness. Onset of action Air bubbles do not alter the onset of action of the medication.

New medications

All HCPs should be knowledgeable about a medication before administering it. Nurses are not expected to retain the information regarding the numerous medications utilized in client care. Many drug information guides are available for the nurse to reference when unfamiliar with a prescribed medication. If the nurse is unable to locate information regarding the medication, a pharmacist is the next choice for reliable source of information about medications. A nurse cares for a client with a health care provider (HCP) prescription for a newly approved medication with which the nurse is unfamiliar. The nurse is unable to find information about the medication in a drug reference book. Which action does the nurse take? Contact the hospital pharmacist. The pharmacist is the most reliable source of information regarding medications. NOT: Administer the medication to the client. The nurse should not administer a medication without knowing its mechanism of action, expected outcomes, or potential reactions. Ask the client about the new prescription. The client is not an authoritative resource for information regarding a new medication. Call the HCP for an explanation. The HCP needs to be notified if the medication seems to be inappropriate for the client but not because the nurse is unfamiliar with the medication.

Pre-op medications

An NPO client should have nothing by mouth unless specifically prescribed by the provider. When the provider intends for the client to have oral medications prior to a procedure, the order is usually written as "NPO except meds" rather than just "NPO." If a client scheduled for surgery has medications ordered, the nurse needs to contact the provider to determine if the medications should be held until after the procedure or administered prior to the procedure with small sips of water. The provider may want the client to have the medication for a specific reason. If the medication is held, the nurse should document why it was held. A nurse receives the morning report for a client who is scheduled for surgery in 4 hours and is NPO. The client has several scheduled morning medications. Which action does the nurse take next? Contact the health care provider. The nurse should consult the provider to determine if the medications should be administered or held until after the procedure. NOT: Prepare the client for the procedure. The nurse first needs to determine if the client should take the scheduled medications. Administer the scheduled medications. The nurse should not administer the medications without first consulting with the provider. Hold the medications and document. The nurse should not hold the medications without consulting with the provider.

opioid overdose

Clients prescribed opioids require assessment for toxicity or overdose. Toxic effects of medications can result from a prolonged use of medication or when the body does not metabolize or excrete the medication effectively due to impaired kidney or liver function. When treating opioid toxicity, withdrawal symptoms need to be considered as well. Respiratory depression is the most serious adverse effect of opioid toxicity, and the client may need ventilation assistance if it is not prevented soon enough. An assessment of neurologic status (with attention to alertness and level of sedation) are also important components to help determine if opioid toxicity should be ruled out. The nurse who suspects opioid toxicity should contact the health care provider to obtain an order for an opioid antagonist. Symptoms of opioid toxicity include decreased level of consciousness, difficulty arousing, lowered respiratory rate and depth, and (at times) bradycardia. A nurse cares for a client with asthma who is prescribed a hydromorphone patient-controlled analgesia (PCA) set at a basal rate of 0.1 mg/hr with a 0.1 mg bolus every 10 minutes. Which assessment data requires the nurse to contact the provider? Select All That Apply The client has a respiratory rate of 10 breaths/min. A respiratory rate of 10 breaths/min. should be reported to the provider for potential opioid toxicity. The client is difficult to arouse from sleep. A client who is difficult to arouse from sleep may be overly sedated and is at risk for opioid toxicity. The provider should be contacted. NOT: The family reports the client is anxious. Anxiety is not related to the PCA. The client has bilateral wheezes in the lung fields. Wheezing is not associated with the PCA or hydromorphone. The client has a temperature of 100.3° F (37.9° C). A fever is not related to the PCA or the prescribed medication.

breakthrough pain (BTP)

Clients who experience chronic pain are often managed with long-acting opioid pain medication. Sometimes the analgesic effect wears off and the client experiences breakthrough pain. Breakthrough pain comes on suddenly, lasts for short periods, and is not relieved by the client's normal pain management. Treatment with PRN doses of immediate-release dosage forms of medication are often prescribed by the provider in the event this occurs. If a client does not have a prescription for breakthrough pain management, the nurse should contact the provider to obtain a prescription to manage client pain. Sometimes, managing client pain may require adjustment of the scheduled long-acting opioid pain medication. A nurse should not disregard a client's report of pain or make them wait for a scheduled dose. A nurse cares for a client with pain related to fibromyalgia with a prescription for morphine ER 15 mg PO q8hr. The nurse administers morphine ER 15 mg PO at 1400 as scheduled. At 1700, the client reports rapid onset pain of 8/10 and requests additional pain medication. Which response by the nurse is appropriate? "I will check to see if your provider has prescribed a medication for breakthrough pain." For clients with chronic pain conditions, extended-release pain medication is used with prescriptions provided for potential anticipated breakthrough pain. NOT: "I can contact your provider to ask if I can administer another dose of your scheduled medication." Another dose of the scheduled medication is not appropriate. "You will have to wait until 8 pm to receive an additional dose of your pain medication." It is inappropriate for the nurse to inform the client that nothing can be done regarding the report of pain. "Your pain is only related to your walking in the hallway and should be better after you rest." The nurse cannot assume that the pain is only temporary and needs to provide appropriate intervention.

Central line dressing change

Clients with central lines are at increased risk for infection. Careful dressing changes reduce risk of infection. Wash hands before starting, then put on a mask and clean gloves, remove the old dressing, put on sterile gloves, clean the catheter site with chlorohexidine, and apply a new sterile dressing. Central lines (also called CVAD or CVC) lie in the superior vena cava, near the heart, and remain in place for extended periods of time. Failure to prevent blood stream infections due to central lines costs the health care system, the facility, and can result in morbidity or mortality for clients. CLABSI are preventable through good hand hygiene, appropriate site care, and prompt removal of line when no longer required. Clients with femoral central lines are at greatest risk for CLABSI. The nurse cares for a client with a central venous access device. The nurse performs what actions to reduce the risk of central line-associated bloodstream infections (CLABSI)? Select All That Apply Change wet insertion site dressing promptly. Change soiled or wet dressings immediately. Try to keep central line site clean and dry. Clean the insertion site with chlorohexidine. Chlorohexidine is used to clean the site before insertion and with central line dressing changes. Wash hands before handling the device or site. The nurse washes hands before handling the central line, every time, to reduce infection. NOT: Avoid using gauze dressings on the insertion site. Sterile gauze dressings or semipermeable transparent dressings are acceptable. Gauze dressings are preferred for central lines with bleeding or drainage. Hospital policy usually states how often to change gauze dressings, usually every 48 hours. Change the central line dressing every day. Change soiled or wet dressings immediately. Otherwise, change gauze dressings every two days and semipermiable transparent dressings every seven days. Transparent dressings alone are changed every 5-7 days unless soiled.

Diphenhydramine (Benadryl)

Diphenhydramine is a first-generation antihistamine. Side effects of this class of drugs include sedation and the anticholinergic effects of dry mouth, blurred vision A nurse cares for a client who develops hives after the administration of blood products. The health care provider prescribes diphenhydramine 25 mg IV push. Which statement by the client indicates an understanding of the side effects of the medication? Select All That Apply "I may get sleepy and want to take a nap." Antihistamines have a sedative effect. "I may have trouble reading my book for a while." Blurry vision is a common side effect of antihistamines, which may make reading difficult. "I should make sure my water pitcher is full of water." Dry mouth is a common symptom of antihistamine medications, and the client understands the need to have fluids readily available. NOT: "I may not make it to the bathroom without wetting myself." The client may have difficulty urinating, not incontinence. "I may notice that I have to spit more than usual." Excessive salivation is not a side effect of antihistamines.

Rectal route of administration

Drug administration via the rectal route is preferred for certain drugs that may be destroyed in the gastrointestinal (GI) tract or when oral administration (PO) is not possible because of vomiting or difficulty swallowing PO medications. The medication is dissolved at body temperature. Absorption may not be faster due to small surface areas, but most drugs have an increased extent of absorption even when the rate of absorption is not increased. This is because per-rectum drugs avoid the hepatic first-pass effect. For this reason, rectal doses are frequently lower than PO doses and the effects may be seen sooner. The nurse prepares to administer a medication rectally to a client. Which is true regarding rectal medication administration versus PO administration? There may be a shorter period of time before the nurse notes the effectiveness of medication administration. Though the rate of absorption is not faster, these drugs by-pass the liver and so the effect is often quicker than oral administration. NOT: Clients who receive medications by the rectal route tend to develop hypersensitive reactions more readily. Hypersensitive reactions are no more common with the rectal route than with any other route. Administration of rectal medication may result in constipation issues with the client. Constipation is not an anticipated effect of rectal administration. The nurse should monitor the client more for rectal bleeding after medication administration. Rectal bleeding is not an expected effect of rectal administration when administered correctly. It may be a sign of another problem.

Drug-food interactions

Drug-food interactions are common and may be avoided if the nurse provides adequate teaching on the risks associated with various food or beverage options. Statin medications may interact with grapefruit juice, levothyroxine interacts with fiber, and beta blockers interact with high-potassium foods. It is very rare that a food type must be avoided altogether. Typically a food type must be eaten in consistent amounts daily to maintain a drug's blood level, not taken at the same time as a medication dose, or limited in some other way. A nurse provides discharge teaching to a client. After reviewing the health care provider's prescriptions, what does the nurse teach? (See exhibit.) Select All That Apply View Exhibits "Avoid drinking grapefruit juice." Clients taking statin medications (simvastatin) should avoid drinking grapefruit juice because grapefruit juice can increase the absorption of the medication, increasing the risk of toxicity. "Limit potassium-rich foods." Beta blockers (metroprolol) limit the uptake of potassium from the bloodstream so if a client consumes a high-potassium diet, the risk of hyperkalemia is increased. "Eat consistent amounts of fiber." Levothyroxine has decreased absorption when consumed with high fiber meals. Fiber-rich foods should not be eaten with the dose, but should be eaten in similar quantities each day so that the levothyroxine dose can be adjusted to maintain therapeutic effectiveness. NOT: "Buy low calcium foods." The medications listed in the client's MAR do not interact with calcium and this would not be something the nurse instructs the client on. "Take an iron supplement daily." The nurse does not have a reason to instruct the client to change dietary habits related to iron consumption.

Central line insertion

During central line insertion, the nurse carefully hands objects to the HCP who wears sterile gloves and gown, a hat and a mask. The nurse wears clean gloves, hat and mask. Maintaining aseptic technique during this process reduces risk of central line-associated blood stream infections (CLABSI). The client requires an emergent central venous access device placement. The nurse assists the health care provider (HCP) through the procedure in what order? (Place each option in order, from first task to last.) Wash hands with soap and water. Don sterile gown and gloves. Clean insertion site with chlorohexidine. Apply sterile gauze dressing to the site. Dispose of any sharp objects. A CVC may be placed in a large vein in the neck, arm, groin, or through the chest, but the tip of a CVC should be in the superior vena cava. If the CVC tip is situated high up (in the subclavian vein), it can cause vessel wall erosion. If the CVC tip is very low (in the right atrium), it can cause arrhythmias and damage to the tricuspid valve. A client returns from placement of a central venous catheter (CVC) placement. The nurse reviews the results of the chest X-ray. Which action does the nurse take? (See exhibit.) View Exhibits Initiate total parenteral nutrition infusion. With verification of placement in the superior vena cava, the nurse can proceed to use the central line. NOT: Prepare the client for replacement of central line. The central line is correctly placed, and the client does not need for it to be replaced. Contact the health care provider. There is no need to contact the health care provider with verification of placement. Remove the central line. The central line is correctly placed and does not need to be removed. With central IV therapy, an access device is placed in the central circulation, within the superior vena cava, near the junction with the right atrium. This places the client at increased risk for pneumothorax; therefore, a chest X-ray is needed to confirm catheter location and the absence of a pneumothorax prior to using the central line. A nurse cares for a client who has a peripherally inserted central catheter placed. Which action does the nurse take when the client returns to the unit after placement? Review X-ray results after procedure. X-rays should be reviewed for verification of placement prior to initiating use of the central line. The tip of the line should rest in the superior vena cava at the cavoatrial junction. NOT: Apply a clean, dry dressing to the site of insertion. A dressing should be in place when the client returns. Dressings are changed every 7 days or if soiled. Initiate IV fluids as prescribed. Fluids should be initiated after verification of placement by X-ray. Review health care provider prescriptions for pain medications. The client may have some discomfort from the procedure. If the client has enough pain to require medications, the catheter needs additional evaluation immediately.

Potassium Chloride IV infusions

If administered too quickly, KCL can lead to cardiac arrhythmia, resulting in cardiac arrest. The concentration and rate need to be appropriate for the IV route. KCL should be administered at a rate of 10 mEq/hr when using a peripheral IV line to reduce site irritation. 20 mEq/hr is appropriate for a central line. To administer 20 mEq/100 mL at a rate of 10 mEq/hr, the nurse would use ratio and proportion to determine the rate at which to set the infusion pump. 10 mEq/hr ÷ x mL = 20 mEq/hr ÷ 100 mL; 20x = 1,000; x = 50 mL/hr. A nurse receives a prescription for potassium chloride (KCL) 40 mEq IV. The client has a potassium level of 2.9 mEq/L and a peripheral IV catheter. The nurse removes two 20 mEq KCL/100mL bags from the medication dispensing system. At what rate does the nurse set the infusion pump for each 20 mEq/100mL bag? (Record your answer rounding to the nearest whole number.) Answer:50 mL/hr

IV Pain Medications

IV pain medications such as morphine take 15 to 30 minutes to peak. Although some relief may come with drug onset, the nurse should reassess for pain 30 minutes after administration to ensure that peak efficacy has been achieved. A nurse administers 20 mg of morphine sulfate IV to a client at 0400 for a reported pain level of 6/10. When does the nurse reassess the client's pain rating? At 0430 The medication should peak at 30 minutes, and the nurse will be able to determine effectiveness of medication administration. NOT: At 0500 By 0500 the medication will have already peaked, although the client may still be comfortable. Best practice with IV medication administration is to evaluate effectiveness 30 minutes after administration. At 0530 By 0530 the medication will have already peaked, although the client may still be comfortable. Best practice with IV medication administration is to evaluate effectiveness 30 minutes after administration. At 0600 By 0600 the medication will have already peaked, and the client may have begun to feel discomfort. Best practice with IV medication administration is to evaluate effectiveness 30 minutes after administration.

Lacted Ringers

In this case, the only clarification needed is related to the use of lactated Ringer's given the evidence of metabolic alkalosis and obtaining an order for a more appropriate solution to treat the client's dehydration such as normal saline with 20 mEq potassium chloride per liter. The nurse is responsible to review new orders to ensure appropriateness for the client's current condition. The nurse's knowledge of pathophysiology, pharmacological properties, and treatment protocols enables proper communication of concerns for optimal treatment decisions. The nurse reviews new prescription on a client with a history of left heart failure who is admitted for viral gastroenteritis, diarrhea, and dehydration. The nurse contacts the health care provider for what reason? (See exhibit.) View Exhibits To clarify the order for lactated Ringer's solution. The client's arterial blood gas results indicate metabolic alkalosis (elevated pH, elevated HCO3 [bicarbonate], and an elevated paCO2 in compensation). The lactate in Ringer's solution is metabolized to bicarbonate and may worsen metabolic alkalosis. NOT: To clarify the amlodipine and metoprolol order. The client is neither significantly hypotensive nor bradycardic so there is no need to have these medications altered at this time. To request an order for an antidiarrheal. Viral diarrhea should not be treated with antidiarrheal medications as this prevents the shedding of the virus. There is potassium contained in the Ringer's lactate solution and if hypokalemia persists, a supplement may be needed. To clarify holding the furosemide. The client is admitted for dehydration so the order to hold the loop diuretic is clinically indicated and does not require clarification.

Insulin glargine (Lantus)

Insulin glargine (Lantus) is a long-acting insulin. Given once per day for steady, 24-hours glucose control, Lantus is often used in combination with other medications for optimal control of diabetes. Additional anti-diabetic medications that may be used in combination with Lantus work on control via mechanisms that include decreased absorption of glucose, decreased insulin resistance in the cells, increased secretion of insulin, decreased production of glucose from the liver, increased uptake of glucose in the cells, and decreased absorption of glucose.

Lipodystrophy

Lipodystrophy occurs when the body continuously pulls insulin from the subcutaneous fat in one area, causing atrophy of the subcutaneous tissue at that injection site. This creates divots in the skin, giving the skin the appearance of an orange peel, which is irreversible. Lipodystrophy can cause unpredictable insulin absorption in the affected area. This can be avoided by rotating injection sites. A nurse educates a client with a new diagnosis of Type 1 diabetes on insulin administration. Which statement by the client requires the nurse to provide additional education? "I should use the same spot every time I give myself a dose of insulin." To prevent lipodystrophy, injection sites should be rotated. OK: "I can give the injections in my belly or in my upper arm." Acceptable subcutaneous sites are the lateral abdomen, upper outer arms, upper outer thighs, and upper buttocks. "I can store my insulin and supplies on the kitchen counter." Insulin can be stored at room temperature unless temperatures are extreme. "If I feel I need to skip my insulin dose, I should call my provider first." The client should notify the provider for further instructions when ill or with hypoglycemia and insulin is held.

Midline Catheters

Midline catheters are used in place of peripheral IV's to avoid repeated IV placement, client discomfort, and to save the nurse time from replacing IV's. The client who needs IV therapy of medications that are safe to run through a peripheral IV for 1-4 weeks is an excellent candidate for the midline catheter. The tip of the midline catheter lies in the upper arm, and is not considered a central catheter. Therefore, medications that are vesicants such as chemotherapy, TPN, and vasopressors should not be infused through the midline catheter. Midline catheters require sterile technique during insertion and dressing changes because they typically are used for one to four weeks. The nurse knows which client is the best candidate for a midline catheter? The client requiring daily IV antibiotics for one month. The client requiring daily antibiotics for one month is the best candidate for a midline catheter. The midline catheter would save this client from the pain and inconvenience of frequent IV restarts. NOT: The client requiring intravenous heparin for two days. Midline catheters are appropriate to use for heparin administration. However, it is appropriate to administer short-term heparin infusions through a peripheral IV catheter. The client needing daily laboratory draws for one week. Blood may be drawn from a midline catheter, but the nurse avoids drawing blood routinely from a midline catheter. The client requiring a two liter fluid bolus over one hour. The nurse could administer a two liter fluid bolus through a peripheral IV or a midline catheter. However, as this is a short-term infusion, this client would not be the best candidate for a midline catheter.

Clozapine (Clozaril)

Neutropenia is a decrease in the neutrophil count in the blood. Clients with a decreased neutrophil count are at increased risk for infection because neutrophils are cells that fight infectious agents. Some drugs increase the risk of developing neutropenia, including clozapine. Clients on clozapine should be monitored for signs of infection. Laboratory work should be checked regularly for decreasing WBCs and neutrophils. Normal WBC is 4000-10,000 per mm³. An absolute neutrophil count of less than 1,000 per mm³ would require precautions to prevent infection and likely discontinuation of the medication until levels return to normal. Clients on clozapine are registered, and adverse effects are tracked by each manufacturer on a registry. A nurse cares for a client on the psychiatric unit for an episode of acute schizophrenia. The client's home medications include clozapine for the last 2 weeks. Which finding does the nurse recognize as an adverse effect of clozapine? Neutropenia Clozapine therapy may cause neutropenia, a decrease in the neutrophil count in the blood. NOT: Anemia Anemia is a decrease in RBCs and is not the result of clozapine therapy. Leukemia Clozapine therapy does not cause leukemia, which is a blood malignancy. Thrombocytopenia Clozapine therapy does not cause thrombocytopenia, which is a decreased production of platelets.

Nonadherence

Nonadherence is a common nursing diagnosis used to manage a client's drug regimen. Noncompliance can be related to many issues, including complexity, cost of medications, duration of the treatment, values, access, and knowledge. A home health nurse visits an older adult client. The client reports difficulty remembering to take daily medications. Which problem is most appropriate for the nurse to address for this client? Nonadherence A client who does not follow treatment regimen regardless of indication is nonadherent. NOT: Risk of self-harm The client is not intentionally seeking to perform self-harm. Loss of hope There is no indication of loss of hope in this client. Deficient knowledge The client has memory issues, which is not a knowledge issue.

Rights of Medication Administration

Nurses use two client identifiers prior to medication administration. Acceptable client identifiers are the client's name, date of birth, or an identification number assigned by the health care agency. Facility protocols determine which two identifiers should be used. Checking the client's ID band is the best-practice option because the band is placed on the client during admission and should not be removed. However, it is also acceptable for the client to verify his or her name if able to do so. When the client is a minor, asking the parent or legal guardian to identify the client is acceptable, in addition to comparing the ID band with the medical information record. A nurse prepares to administer scheduled medications to a client. Which information does the nurse use to verify client identity? Select All That Apply Ask the client to state his or her full name. If the client is able, the nurse can have the client state his or her full name. Ask the client to state his or her date of birth. If the client is able, the nurse can have the client state his or her date of birth. Check the name on the client's armband. The nurse can verify that the client name on the medication administration record matches the client's armband. NOT: Ask a family member to identify the client. The only authorized family members to identify a client would be the parent or legal guardian of a minor. Check the client's room number. A client's room number is not an acceptable client identifier.

Oral Pain Medication

Oral medications generally take about one hour to peak. Evaluation of effectiveness should take place when the medication is peaking. The nurse administers hydromorphone 1 mg PO at 1300 to a client who reports moderate abdominal pain of 6/10. When does the nurse reevaluate the client's pain level? At 1400 Hydromorphone peaks in 30-60 minutes. Evaluation at one hour is appropriate. NOT: At 1315 An oral medication does not work within 15 minutes unless it is an immediate release formulation. At 1430 The medication will begin to lose peak levels of effectiveness after 1 hour, so evaluation at 1430 is inappropriate. At 1500 The medication will begin to lose peak levels of effectiveness after 1 hour, so evaluation at 1500 is inappropriate.

Neonatal IV Therapy

Parenteral fluids can be administered to neonates via several routes, with the preferred route being the umbilical venous catheter. Neonates are at particular risk for fluid overload because of their size. Initiating an IV infusion at 400 mL/hr on an infant should be questioned. When infusing, rates should be regulated at minute volumes and checked hourly to prevent fluid overload. A nurse cares for a client in the neonatal intensive care unit for respiratory distress syndrome. The nurse reviews the health care provider (HCP) prescriptions, noting an IV infusion at 400 mL/hr. Which action does the nurse take next? Contact the HCP regarding the prescription. The nurse would contact the HCP to clarify the volume of administration for a neonate. NOT: Begin the prescribed IV fluid infusion. The nurse would first contact the HCP, as this volume is too large for a neonate. Check the radiant warmer setting is at 37° C (99° F). The nurse should confirm the radiant warmer is set to maintain the neonate's temperature when IV solutions are infusing, but only after verifying with the HCP the volume to be infused. Ensure patency of the client's umbilical venous catheter. Neonates will usually have an umbilical catheter in place. Prior to use, the nurse should ensure patency, but only after verifying with the HCP the volume to be infused.

Prescription order

Physician signature, client's full name, drug name, dosage, route, time schedule, order date, and time should be included in all medication orders. The route should always be included. Acetaminophen is available in oral and rectal routes. A nurse reviews provider prescriptions for a newly admitted client. Which medication prescription requires the nurse to contact the provider? (See exhibit.) View Exhibits Acetaminophen The acetaminophen does not have a route, and the nurse should contact the provider for order clarification. NOT: Albuterol The albuterol (Proventil HFA) order includes a dosage, route, and frequency of use. Montelukast sodium The montelukast sodium (Singulair) order includes a dosage, route, and frequency of use. Prednisone The prednisone (Deltisone) order includes a dosage, route, and frequency of use. Providers write prescriptions based on the frequency or urgency of the needed medication or treatment for a client. Nurses should be aware of existing prescription protocols for standard client care at the facility and on the unit. A standing prescription, or protocol, establishes guidelines for administering medications or treatments in specific situations with specific criteria. Standard prescriptions will be provided for client care for routine and scheduled medications. STAT or NOW prescriptions should be given immediately as they are for urgent client needs. PRN (as needed) prescriptions are administered based on specific client assessment and nursing judgment. The nurse reviews health care provider prescriptions for a newly admitted client who has pneumonia. Which type of prescription is the acetaminophen order? (See exhibit.) View Exhibits PRN PRN (as needed) orders are prescribed for a specific client need or with specific guidelines. NOT: STAT A STAT or NOW prescription should be initiated immediately. Routine A standard prescription is a routine and scheduled prescription. Protocol Protocol prescriptions are established guidelines developed by a facility or unit with consensus among providers. The nurse notes the furosemide is prescribed to be administered NOW. This means the order is a STAT order and must be administered within 30 minutes of the prescription being written. Standard or protocol orders should be administered within 30 minutes on either side of the scheduled time for administration. For example, if a medication is to be administered at 0800, the nurse can administer it between 0730 and 0830. PRN medications are given at special times or under certain circumstances, depending on client assessment. A nurse reviews a client's electronic health record for new provider prescriptions after 1200. The nurse recognizes the furosemide prescription as which type of medication prescription? View Exhibits Urgent A STAT (Latin for "immediately") or NOW order is to be given immediately. NOT: As needed A PRN (Latin for pro re nata, meaning "when necessary") prescription is a medication to be administered as needed as detemined by client condition or report. Protocol A protocol order is based on a set of guidelines and protocols determined by providers or a facility. Routine A standard written order or routine order is written for medication to be administered at set times on an ongoing basis.

IV Push

Prior to administering medication using a saline lock, the nurse must complete a number of steps. 1. After verifying client identity by two client identifiers, the nurse cleanses the port of the lock with an approved antiseptic solution. 2. The nurse attaches a syringe with 5 to 10 mL of normal saline. 3. Before flushing, the nurse verifies correct placement by aspirating to check for blood return. 4. After verification, the nurse flushes the line with 5 to 10 mL of normal saline or an appropriate volume to clear the tubing. 5. The nurse removes the saline syringe and cleans the port again prior to attaching the syringe with medication. After Steps 1-5, the medication is pushed according to the recommended time per institutional or pharmacological policy. After administering the medication, the nurse flushes the line with 5 to 10 mL of normal saline at the same rate at which the medication was administered. A nurse prepares to administer a first dose of morphine sulfate 2 mg IV to a client who has a saline lock for PRN IV medication administration. Which actions does the nurse take prior to administration? Select All That Apply Flush the line with 5 to 10 mL of normal saline. The line should be flushed with a syringe of normal saline prior to use. A short (in length) catheter may require less volume but up to 10 mL is accepted as best practice. Ensure the IV catheter is patent. The nurse should verify for vein placement by checking for blood return prior to flushing the line. Sometimes a blood return cannot be obtained. The nurse ensures the catheter flushes easily and without discomfort or changes at the site. Verify the client's identity using two client identifiers. The client's identity should be verified by checking two identifiers. Clean the injection port of the saline lock with antiseptic. The port should be cleansed with an approved antiseptic prior to flushing or administering medication. NOT: Disconnect the tubing from the site and attach syringe for flushing. The tubing should not be removed from the hub of the catheter.

Sim's Position (Left Lateral Recumbent/ Left Lateral Position)

Sims position, or left lateral recumbent, is the preferred position for administering an enema because it uses gravity to help the fluid move through the curve of the colon. It is also used for rectal exams. In Sims position, the client's left leg is straightened and the right leg is flexed at the hip and knee, providing stability. A nurse prepares to administer an enema to a school-age client who has severe constipation. In which position does the nurse place the client prior to administration? Sims Sims position is the preferred position for administering an enema. NOT: Trendelenburg Trendelenburg position has the head of the bed lower than the lower extremities; it is not appropriate for administration of an enema. Prone Prone position has the client lying on the stomach; it is not appropriate for administration of an enema. Supine Supine position has the client lying on the back; it is not appropriate for administration of an enema.

central line removal

Steps are taken to increase central venous pressure (CVP), which is normally lower in blood vessels above the level of the heart and also during inspiration.The client should be placed in the Trendelenburg position with a downward tilt of 10 to 30 degrees. This is to promote venous filling, raise CVP, and ensure that the catheter exit site (for example, neck and arm) is lower than the height of the client's heart. If not possible, supine position is sufficient. Instruct the client to hold his or her breath and perform a Valsalva maneuver (bear down) unless contraindicated. Trendelenburg position increases central venous pressure to reduce the risk of air embolism. Pressure is applied to the site for 5 minutes after the removal and then the client remains in a supine position for at least 30 minutes. A nurse prepares to discontinue a client's central venous catheter (CVC). Which actions does the nurse take? Select All That Apply Instruct the client to take a deep breath and hold it. Instructing the client to take a deep breath and hold it helps to reduce the risk for air embolism during catheter removal. Position the client in Trendelenburg position. Positioning the client in Trendelenburg position assists in increasing central venous pressure. NOT: Elevate the head of the client's bed. Elevating the head of the bed does not assist in increasing central venous pressure. Flush the central line catheter with heparin. Flushing the catheter with heparin is not indicated prior to removal. Instruct the client to breathe slowly and deeply. The client should be instructed to take a deep breath and hold it as the catheter is removed.

Suppository

Suppositories should not be administered to clients with diarrhea because the medication will discharge unabsorbed with the stool. The health care provider should be contacted to obtain a prescription by a different route. As the nurse prepares to administer a suppository to a client per provider prescription, the client reports recent episodes of diarrhea. Which action does the nurse take? Withhold the medication and contact the health care provider. The nurse should withhold the medication due to the great potential for it being expelled. The nurse should contact the provider to obtain a prescription by an alternate route. NOT: Contact the pharmacy and obtain an oral dose of medication. The nurse cannot change the route of medication administration without contacting the health care provider. Instruct the client to insert the suppository while in the bathroom. The suppository should not be administered while the client is experiencing diarrhea. Administer the medication 10 minutes after the last stool. The nurse should not administer the medication by the rectal route while the client is experiencing diarrhea.

Schedule Drugs

The Controlled Substance Act (1970) established schedules for the administration of controlled substances, requiring specific education related to addiction and to help prevent drug dependency and addiction. Schedule I and II drugs have a high risk of physical and psychological dependence. Schedule III drugs have a low-to-moderate risk for physical dependency and a high risk for psychological dependency. Schedule IV drugs carry limited risk for physical and psychological dependency. Schedule III medications can be provided by oral or written prescription. The prescription must be filled within six months or it becomes invalid. The prescription can be refilled no more than five times in a six-month period of time and must have a warning label for abuse and dependency use. A nurse provides education to a client with a new Schedule III narcotic analgesic prescription due to chronic pain. Which statement by the client requires the nurse to provide additional education? "I will be able to get a refill every month for this medication." Schedule III narcotics can be refilled only five times in a six-month period. NOT: "When I finish, I should have my provider call in the next prescription." Schedule III narcotics may have a written or oral prescription, so a refill could be called in. "I should not drive or perform physical work after taking the medication." Schedule III narcotics can result in drowsiness and decreased alertness, so the client should avoid driving. "If I am still experiencing pain, I should contact my provider." The client should contact the health care provider if relief is not obtained with use.

IV Solutions

The client is in a hypertonic state and should not receive hypertonic fluid. The client should be given isotonic solutions such as 0.9% saline, 5% dextrose in water (D5W), 5% dextrose in 0.225% saline (D5W¼NS), and lactated Ringer's. Hypertonic solutions include 3% saline, 5% saline, 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (D5NS), 5% dextrose in 0.45% saline (D5½NS), and 5% dextrose in lactated Ringer's (D5LR). Hypotonic solutions include 0.45% saline (½NS), 0.225% saline (¼NS), and 0.33% saline (⅓NS). A nurse cares for a client with an elevated serum osmolality and a serum sodium level of 159 mEq/L. Which fluid prescription would require the nurse to contact the health care provider? Dextrose 5% in normal saline (D5NS) at 100 mL/hr This is a hypertonic solution and is not appropriate. NOT: Dextrose 5% in water (D5W) at 100 mL/hr This is an isotonic solution and is appropriate. 0.9% saline at 100 mL/hr This is an isotonic solution and is appropriate. Lactated Ringer's at 100 mL/hr This is an isotonic solution and is appropriate. Isotonic solutions have equal osmolarity with serum. This does not create a concentration gradient and will not move fluids into or out of the vascular space. Hypotonic solutions contain fewer solutes than serum, making their osmolarity lower. This will lower the serum osmolarity, causing fluid to move from the vascular space to the intracellular compartment where there is greater osmolarity for dilution (due to the concentration gradient). Hypertonic solutions contain more solutes than serum, making their osmolarity higher. This will raise the serum osmolarity, causing fluid to move into the vascular space from the extracellular compartment by diffusion (due to the concentration gradient). One example is D5½NS. A nurse prepares to initiate an IV infusion to a client with pulmonary edema. The nurse understands the need for which type of IV fluid for this client? Hypertonic Hypertonic solutions move water out of cells into the bloodstream, helping to eliminate pulmonary edema. NOT: Hypotonic Hypotonic solutions move water into cells, causing them to expand. Isotonic Isotonic solutions do not allow water to move in or out of cells. Crystalloid Crystalloid solutions may be isotonic, hypertonic, or hypotonic. Hypotonic solution contains fewer solutes than the serum, making its osmolarity lower. This will lower the serum osmolarity of the blood and the excess fluid in the blood will move out of the vascular space into the intracellular compartment by diffusion (due to the concentration gradient). The fluid moves to where the solutes are more concentrated to try to balance it out. Hypotonic solutions include 0.45% saline (½NS), 0.225% saline (¼NS), and 0.33% saline (⅓NS). Hypertonic solution contains more solutes than the serum, making its osmolarity higher. This will raise the serum osmolarity of the blood and pull fluid from the intracellular compartment into the vascular space by diffusion (due to the concentration gradient), thus raising the blood volume. Hypertonic solutions include 3% saline, 5% saline, 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (D5NS), 5% dextrose in 0.45% saline (D5½NS), and 5% dextrose in lactated Ringer's (D5LR). Isotonic solution has equal osmolarity compared to normal serum. This does not create a concentration gradient and does not pull fluids into or out of the vascular space, so it allows rehydration that expands blood volume but also allows fluid to move into the intracellular compartment as needed. Isotonic solutions include 0.9% saline, 5% dextrose in water (D5W), 5% dextrose in 0.225% saline (D5W¼NS), and lactated Ringer's. A nurse prepares to administer IV fluids for a client who needs fluid pulled into the intracellular space. Which prescription requires the nurse to contact the health care provider? 0.9% saline at 100 mL/hr This is an isotonic solution and is not appropriate. NOT: 0.225% saline at 100 mL/hr This is a hypotonic solution and is appropriate. 0.45% saline at 100 mL/hr This is a hypotonic solution and is appropriate. 0.33% saline at 100 mL/hr This is a hypotonic solution and is appropriate. Hypotonic solution contains fewer solutes than the serum, making its osmolarity lower. This will lower the serum osmolarity of the blood and the excess fluid in the blood will move out of the vascular space into the intracellular compartment by diffusion (due to the concentration gradient). The fluid moves to where the solutes are more concentrated to try to balance it out. Hypotonic solutions include 0.45% saline (½NS), 0.225% saline (¼NS), and 0.33% saline (⅓NS). Hypertonic solution contains more solutes than the serum, making its osmolarity higher. This will raise the serum osmolarity of the blood and pull fluid from the intracellular compartment into the vascular space by diffusion (due to the concentration gradient), thus raising the blood volume. Hypertonic solutions include 3% saline, 5% saline, 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (D5NS), 5% dextrose in 0.45% saline (D5½NS), and 5% dextrose in lactated Ringer's (D5LR). Isotonic solution has equal osmolarity compared to normal serum. This does not create a concentration gradient and does not pull fluids into or out of the vascular space, so it allows rehydration that expands blood volume but also allows fluid to move into the intracellular compartment as needed. Isotonic solutions include 0.9% saline, 5% dextrose in water (D5W), 5% dextrose in 0.225% saline (D5W¼NS), and lactated Ringer's. A nurse prepares to administer IV fluids to a client who needs fluids pulled into the vascular system. Which prescription requires the nurse to contact the health care provider? 5% dextrose in 0.225% saline at 75 mL/hr This is an isotonic solution and is not appropriate. OK: 5% dextrose in lactated Ringer's at 75mL/hr This is a hypertonic solution and is appropriate. 5% dextrose in 0.9% saline at 75 mL/hr This is a hypertonic solution and is appropriate. 5% dextrose in 0.45% saline at 75 mL/hr This is a hypertonic solution and is appropriate.

Patient Teaching

The first step of teaching is assessment of the client ability to understand and comply. Some clients may be able to self-administer lovenox, while other clients may not be able to self-administer lovenox due to physical condition, inability to understand, or discomfort with needles. Based on this assessment, the nurse tailors the education and the discharge plan to meet the client's needs. A client who cannot self-administer lovenox may need a family or friend to administer the injection. If a family or friend is not available, the nurse develops alternate plan, such as home health care. The health care provider (HCP) prescribes enoxaparin for a client with a deep vein thrombosis (DVT). The client will continue enoxaparin injections at home after hospital discharge. The nurse takes what action to best ensure the client is prepared? Observe the client self-administering the enoxaparin injection. Assessing the client's ability to administer injections is the first step to planning for lovenox at home. Then the nurse observes the client self-administering the medication to make sure the teaching was understood. This is the best evidence of the client's preparedness. The goal of discharge is to continue the care started at the hospital for the client and avoid complications. NOT: Provide the steps of administration in writing with pictures. Providing the steps of lovenox administration in writing is beneficial after assessing the client's ability to administer the injection and before observing the client's self-administration technique. Demonstrate the steps of enoxaparin injection to the client. Demonstrating the steps of injection occurs after assessing the client's ability to administer the injection and before observing the client's self-administration technique. Ask the client to view a video demonstrating injection technique. The client may benefit from watching a video regarding administration techniques, but the nurse must observe the client performing an injection to ensure safety and preparedness.

International Normalized Ratio (INR)

The international normalized ratio (INR) is monitored for clients who have bleeding issues or are on anticoagulant therapy. A normal INR is less than 2. A client with an INR of 3.9 is at increased risk for bleeding. Because muscles are highly vascular, the nurse should avoid IM injections due to risk for bleeding and hematoma formation. Because the client's pain medication is ordered by an IM route, the nurse would need to contact the HCP to determine an alternative route for pain medication administration to prevent harm to the client. A nurse cares for a client with osteomyelitis and a history of a gastrointestinal bleed. The client reports bone pain of 6/10 and requests pain medication. The nurse reviews the client's medical record and health care provider (HCP) prescriptions. Which action does the nurse take? (See exhibit.) View Exhibits Contact the HCP. The nurse should contact the HCP to obtain a prescription for an alternate route of administration for the morphine. NOT: Reassess the client's pain in 30 minutes. The nurse must first provide intervention to decrease the client's level of pain before reassessing. Administer acetaminophen as prescribed. The acetaminophen order is for mild pain, and 6/10 is more than mild pain. Administer morphine sulfate as prescribed. The nurse should not administer the IM injection due to the client's international normalized ratio of 3.9.

Kidney and Liver Function

The kidneys and liver break down and eliminate medications from the body. Premature neonates in particular may have suboptimal growth and maturation of the kidneys and liver. Kidney and liver function decline with age. Therefore, the older client and the premature neonate may have altered ability to metabolize drugs. A nurse reviews drug interactions for different age populations. The nurse understands it is important to verify kidney and liver function in which client populations? Select All That Apply Older adults Aging adults have a decline in kidney and liver function over time. Premature neonates Neonates have immature kidneys and livers. A premature neonate will have even more immature kidney and liver function than a full-term neonate. NOT: Middle-aged adults Middle-aged adults are expected to have normal kidney and liver function without presence of disease. School-aged children School-aged children are expected to have normal kidney and liver function. Adolescents Adolescents are expected to have normal kidney and liver function.

Medication documentation

The nurse is responsible for documenting the administration time, dose, and any reactions, including the effectiveness of pain medications or any adverse reactions to drugs that the client may experience. The documentation should note if there is or is not an improvement in client condition or symptoms after medication administration. It should also note if the client experiences any adverse or toxic effects of the medication. A nurse prepares and administers scheduled 10 a.m. medications to assigned clients. Which information does the nurse include in the client's health record related to medication administration? Select All That Apply Client's reaction to medication The nurse should document the client's reaction to the medication, including effectiveness. Time of administration to client The nurse should document the time of administration. Dose of the medication administered The nurse should document the dose of medication administered. NOT: Mechanism of action of medication It is not necessary to document the mechanism of action of the medication. Time of expected reaction to medication It is not necessary to document the time of expected reaction to the medication. A medication omission is a documentation error that can greatly impact a client. If a nurse forgets to document a medication, and it is accidentally given twice, the outcome may be severe or even cause death. The nurses notes should match the MAR of a client's health record, but it is essential that medication administration be documented in the MAR to prevent double doses. A nurse manager determines that a staff nurse has made an error that is evidenced in the client's medical health record. The nurse manager's decision is based on what concept? (See exhibit.) View Exhibits Inadequate medication documentation. The nurse documents that morphine sulfate is administered at 1600 but the MAR does not indicate this. This shows omission of an entry in the MAR and is an example of inadequate documentation. NOT: Inability to recognize worsening condition. The client's medical record does not necessarily indicate a worsening condition based on the nurse's notes and vital signs of the client. Incomplete nursing note documentation. The nursing note was complete as written. Incorrect administration of a medication. Although the medication is not documented correctly, this is not considered an incorrect administration of a medication.

Medication questions

The pharmacist is trained to answer questions about medications and should be used as a resource for all medication questions. IV compatibility books are on the market, and oftentimes a system is integrated into the electronic medical record. This is an appropriate resource. A nurse cares for a client in diabetic ketoacidosis (DKA) who develops a urinary tract infection (UTI). The client is receiving an IV insulin infusion. The provider prescribes IV azithromycin for the UTI. How does the nurse verify the compatibility of the insulin and the IV azithromycin? Select All That Apply Contact the hospital pharmacist. The hospital pharmacist is an appropriate resource for gathering information about a medication. Review the IV drug book. An IV drug book is an appropriate resource for gathering information about a medication. NOT: Contact the health care provider. The health care provider is not an appropriate resource for gathering information about a medication. Ask the unit charge nurse to verify. The charge nurse is not an appropriate resource for gathering information about a medication. Call the hospital house supervisor. The house supervisor is not an appropriate resource for gathering information about a medication.

Medication error

The responding nurse should immediately stop the infusion to avoid any further harm to the client. The nurse should then notify the new nurse of the error, and the health care provider should be notified to determine the next course of action. After a medication error has occurred, an incident report should be completed following facility policy in order to allow risk management to investigate to prevent future occurences. A nurse responds to a call light to assist a client who is being cared for by a newly hired nurse. The responding nurse notes the client has the incorrect IV medication running. Which action does the nurse take first? Stop the infusion of the medication. The nurse should stop the infusion of the medication immediately. NOT: Inform the orienting nurse of the error. The new nurse should be informed of the error but only after the infusion has been stopped. Call the client's health care provider. The client's provider should be notified after stopping the infusion and assessing for any adverse effects. Complete an incident report on the error. The new nurse will need to complete an incident report. The nurse finding the error may also complete an incident report or may assist in the assigned nurse's report. The health care provider should be notified of the error and any harm to the client. After a medication error has occurred, an incident report should be completed following facility policy in order to allow risk management to investigate to prevent future occurrences. A nurse administers the wrong dose of a medication. After assessing the client, what is nurse's next action? Contact the health care provider. The health care provider should be notified of the error in dosing and the client's reaction or response to the medication. The client's safety is the nurse's priority concern. NOT: Complete an incident report. An incident report should be completed after an assessment of the client has been completed and the provider has been notified. Inform the charge nurse of the error. The charge nurse needs to be notified of the error and the need to complete an incident report, but the provider should first be notified and the client's needs met. Inform the client of the medication issue. It is not necessary to notify the client, but the nurse may do so after the situation is resolved. Research shows that the incidence of errors with injectable medications is higher than with other forms of medications and that two-thirds of all medication administration errors involve injectable medications. Joint Commission Medication Management Standard MM.4.30 requires the labeling of all medications. If a syringe is unlabeled, the content cannot be confirmed and is unsafe to administer. All unlabeled medications should always be discarded and reported as an incident. The previous nurse cannot identify the syringe. The contents of the syringe should be investigated to find if the client missed a dose of medication, but the syringe should also be discarded. After the medication has been disposed of and if determination is made that a dose of medication has been missed, the provider should be notified. A nurse prepares to administer scheduled bedtime medications to a client who has a diagnosis of pneumonia. The nurse finds a filled, unlabeled syringe at the client's bedside. Which action by the nurse is most appropriate? Discard the fluid in the syringe and dispose of the syringe. The best choice is to discard the fluid and the syringe, as the nurse has no knowledge of the content of the syringe. NOT: Inject the filled syringe into the client's IV. The nurse should not inject an unknown fluid into the client's IV. Call the previous nurse and ask about the syringe. Although contacting the previous nurse about the syringe may be appropriate, there is no way for the nurse to verify the contents of the syringe. Contact the health care provider regarding missed medication. The nurse does not know the content of syringe and would be making an assumption to tell the provider that a dose of medication has been missed.

PICC line care

To ensure proper functioning, blood should be aspirated from each PICC lumen prior to administering medication. Absence of blood return may suggest improper placement, an occlusion, or migration of the catheter. Therefore, it would not be safe to administer medication through the lumen that did not have blood return. Infusing through the resistant port where blood was aspirated still leaves the PICC vulnerable to future occlusion, and if the resistance is significant, the line may not work at all. Obtaining a prescription for Cathflo Activase (alteplase) is the best course of action because it addresses the complication and ensures that the PICC is working appropriately before use. A nurse cares for a client who has a peripherally inserted central catheter (PICC). Before using the PICC, the nurse attempts to aspirate blood from one of the two lumens and is unsuccessful. Blood return is attained in the other lumen, but significant resistance is met when attempting to flush it. The nurse performs which action? Notifies the health care provider and suggests use of alteplase, a thrombolytic. Calling the health care provider to suggest a prescription for Cathflo Activase (alteplase), a thrombolytic, would be the best course of action. The client may be experiencing a fibrin occlusion of the PICC. Cathflo Activase (alteplase) binds to fibrin, causing fibrinolysis, and thereby returns patency to the PICC. NOT: Asks the client to forcefully cough while trying to flush the lumen. Asking the client to forcefully cough while trying to flush the line could cause a change in intrathoracic pressure. This change in pressure can cause the catheter to migrate, rendering the PICC unusable and causing further complications. Uses increased force to attempt to flush the lumen that has resistance. Increasing the force used to get the PICC to flush can rupture the catheter. In addition, it may force a clot off the end of the catheter tip and possibly cause embolization. Infuses the medication into the lumen where blood was aspirated. Infusing the medication through the lumen with blood return would not be the best course of action because there is likely an occlusion in the other lumen. Apart from it being a potential safety issue, it does not address the complication. If left untreated, the PICC may completely stop working and cause persistent problems for future infusions.

Platelet transfusion

When caring for a client receiving a platelet transfusion, it is important to understand the potential reactions that may occur. Clients who are more susceptible to developing a reaction, such as those needing frequent transfusions or having hematopoietic stem cell transplantation, should have the risk reduced by receiving platelets from only one donor. It is also important to administer the transfusion appropriately to achieve maximum benefit. The nurse cares for a client receiving a transfusion of single-donor platelets. What does the nurse teach the new graduate nurse about this transfusion? Select All That Apply This reduces the likelihood that the client will experience an allergic reaction. Because the platelets are only from one donor, there is less chance of an allergic reaction occurring. These are suitable for clients undergoing a hematopoietic stem cell transplant. Single-donor platelets are more suitable for clients undergoing hematopoietic stem cell transplantation because of the decreased risk of a transfusion reaction associated with one donor. They may be prescribed to clients needing multiple platelet transfusions. Due to the increased reaction risk associated with frequent transfusions, single-donor platelets are a better option than multiple-donor platelets for those that need repeated transfusions. NOT: Administration should be done using a standard blood tubing set. Standard blood tubing should not be used because the larger filter traps the platelets. In addition, the long length of the tubing allows for greater adherence of the platelets to the lumen. A tubing set with a shorter line and a smaller filter is used. Both the donor's blood type and the recipient's blood type must match. Donor and recipient blood types do not need to match because platelets do not contain the ABO antibodies that are in packed red blood cell transfusions.

ampule medication

When preparing medication from an ampule, the nurse should first wipe the neck of the ampule with alcohol. The nurse should then place gauze around the neck to protect his or her hands from broken glass and break the ampule away from the body. After removing the neck of the ampule, the nurse can draw up the medication with the ampule upside down without spilling the medication. The nurse should use a filter needle to avoid drawing up glass particles that may be inside the broken ampule. When withdrawing medication, the nurse should take care to be certain the needle tip or shaft does not touch the rim of the ampule. The nurse prepares to administer morphine sulfate 4 mg IV to a client reporting pain. The morphine sulfate is in an ampule of 10 mg/mL. Which actions does the nurse take when preparing the medication for administration? Select All That Apply Snap the ampule away from the body. Snapping the ampule away from the body prevents the potential of tiny glass particles from injuring the nurse. Use a filter needle to draw up the medication. A filter needle prevents aspiration of tiny glass particles from being drawn into the medication. Place gauze around the neck of the ampule. Gauze or an alcohol swab will protect the nurse's hands from injury from the broken glass. NOT: Wipe the ampule with an alcohol swab after breaking. Wipe the neck of the vial with alcohol before breaking away from the body. The broken vial should not be wiped with alcohol as this poses a risk for injury. Aspirate the medication from the vial with the needle for injection. The needle to be used for injection should be placed after the medication has been drawn from the ampule through a filter needle. When preparing medication from an ampule, the nurse should place gauze around the neck to protect his or her hands from broken glass and break the ampule away from the body. After removing the neck of the ampule, the nurse can draw up the medication with the ampule upside down without spilling the medication. The nurse should use a filter needle to avoid drawing up glass particles that might be inside the broken ampule. When withdrawing medication, the nurse should take care to be certain the needle tip or shaft does not touch the rim of the ampule. A nursing student prepares to administer dilaudid 2 mg IV to a client. The medication is supplied through the medication dispensing system in an ampule containing 10 mg/mL dilaudid. Which action by the nursing student requires intervention by the supervising nurse? While withdrawing medication, the student rests the needle on the edge of the ampule. Allowing the needle to touch the rim of the ampule can potentially contaminate the medication. OK: The student attaches a filter needle to a syringe prior to withdrawing medication. A filter needle prevents aspiration of tiny glass particles being drawn into the medication. The student snaps the ampule away from the body with a piece of gauze around the neck of the ampule. Snapping the ampule away from the body prevents possible injury from tiny particles of glass. The student verifies the dosage of the medication before removing the ampule from the medication dispensing system. Verification of the dosage of medication is an important step in medication administration.