The health care provider has prescribed 5 mg of intravenous diazepam (Valium) to treat the client in status epilepticus. The client's IV bag is labeled "1,000 mL D5NS with 20,000 units Heparin."
Which nursing interventions are necessary to safely administer this diazepam (Valium)?
Standard Text: Select all that apply.
1. Use a large bore needle to access the IV port.
2. Flush the intravenous (IV) line with saline.
3. Administer the diazepam (Valium) directly into a vein in the client's hand.
4. Dilute the diazepam (Valium) with xylocaine prior to administration.
5. Observe the IV tubing for cloudiness while administering the diazepam (Valium).
Correct Answer: 2,5
Rationale 1: There is no need to use a large bore needle. Most IV administration is done using a needleless system.
Rationale 2: The IV line should be well flushed with saline to remove any residual Heparin, which will precipitate with the diazepam (Valium).
Rationale 3: Direct administration of IV medication is not recommended. The client receiving IV diazepam (Valium) should have an IV established for possible emergency use.
Rationale 4: Diazepam (Valium) precipitates with many drugs and should not be mixed for infusion.
Rationale 5: Diazepam (Valium) precipitates with many drugs. The nurse should watch the IV tubing just above the injection site for cloudiness or development of precipitate during administration and should discontinue the administration if this situation occurs.
Global Rationale: The IV line should be well flushed with saline to remove any residual Heparin, which will precipitate with the diazepam (Valium). Direct administration of IV medication is not recommended. The client receiving IV diazepam (Valium) should have an IV established for possible emergency use. There is no need to use a large bore needle. Most IV administration is done using a needleless system. Diazepam (Valium) precipitates with many drugs and should not be mixed for infusion. The nurse should watch the IV tubing just above the injection site for cloudiness or development of precipitate during administration and should discontinue the administration if this situation occurs.
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