A nurse is caring for a woman on a continuous IV of magnesium sulfate. Which actions are appropriate for patient safety? (Select all that apply.)
A.
Administer the bolus from the main bag, then change to the maintenance rate.
B.
Double-check each new bag and dose/rate change with another nurse.
C.
Ensure that a supply of romazicon (Flumazenil) is available in the patient's room.
D.
Perform handoff report at the bedside, verifying the dose and orders by both nurses.
E.
Place color-coded tags on each IV line, bag, and pump to label them clearly.
ANS: B, D, E
Magnesium sulfate is a high-risk, high-alert drug and the nurse must be cautious about administering this drug safely. Some appropriate actions include double-checking any rate or dose changes with a second nurse, performing the handoff report at the bedside so that both nurses can verify the orders and compare them to the IV bag and pump rate, and color-coding IV lines, bags, and pumps for easy identification. The nurse should ensure that a supply of the antidote (calcium gluconate 10%) is available. However, romazicon is the antidote for benzodiazepine overdose. The nurse should use a small-volume IV piggyback for the bolus dose instead of using the main bag to give the bolus to the patient, and then change the infusion rate to the maintenance setting.
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