The nurse prepares to administer medication in 100 ml of normal saline solution. Which does the nurse implement to mix the medication?
1. Insert the medication into the port for IV tubing.
2. Inject medication through cleansed injection port.
3. Label medication bag using a felt-tip marker.
4. Mix medication for 10 seconds by shaking IV bag.
2
2 and 1. The nurse cleanses the IV bag's injection port, located next to the port for IV tubing, before injecting the medication to avoid contamination of the fluid.
1. The nurse avoids injecting the medication into the tubing port because it is not a self-sealing port.
3. The nurse avoids labeling the IV bag using a felt-tipped marker because the ink can bleed through the plastic and contaminate the solution. The nurse uses an agen-cy-approved label to identify the medication in solution.
4. The nurse gently rotates the solution to mix the medication.
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The nurse is collecting data for a patient suspected of developing a fat embolus from a fracture of the right femur. Which of these manifestations would the nurse expect? (Select all that apply.)
a. Mental confusion b. A migraine c. Numbness in the right leg d. Muscle spasms in the right thigh e. Petechiae f. Tachycardia
When a patient is initially interviewed and assessed, the nurse must: (Select all that apply.)
a. analyze the patient's psychomotor status. b. take the patient's vital signs. c. weigh the patient using a bed scale. d. evaluate the patient's emotional and spiritual needs. e. ensure the coordination of the patient's care.
The daughter of a female client tells the home health nurse that using the bathroom is embarrassing for the client and the client refuses to use a call bell when she needs to get up. Which is the best response by the nurse?
1. Ask the client why she does not use the call bell. 2. Instruct the daughter to remain at the client's side. 3. Tell client that home visits require client cooperation. 4. Discuss call bell alternatives with client and daughter.
For the client with severe acetaminophen toxicity, the nurse should be prepared to administer:
a. N-acetylcysteine (Mucomyst). b. naltrexone (Trexan). c. caffeine. d. magnesium hydroxide (Milk of Magnesia).