An elderly patient receiving an infusion of an isotonic fluid at ...

[Jkov05]

An elderly patient receiving an infusion of an isotonic fluid at 100 mL/hr complains of dyspnea. The nurse notes shallow rapid respirations and a cough that produces frothy sputum. Which is the priority nursing action?
 
  a. Assess the urine output.
  b. Elevate the head of the bed.
  c. Encourage the patient to cough.
  d. Maintain the IV rate.

Question 2

Which technique by the nurse accurately maintains asepsis of a peripheral IV access device?
 
  a. Wear gloves when hanging all IV solutions.
  b. Apply a topical antibiotic ointment to the insertion site.
  c. Change fluid administration sets according to institutional policy.
  d. Flush with heparin before use.

[elizabethrperez]

Answer to Question 1

ANS: B
Elevating the head of the bed is an appropriate action for signs and symptoms of pulmonary edema. Urine output is important to assess, but it is not the priority nursing action. Encouraging the patient to cough and take deep breaths is not the priority nursing action. The IV rate should be slowed immediately based on the signs and symptoms the patient is displaying.

Answer to Question 2

ANS: C
Generally all IV solution bag and bottles should be changed every 24 hours to minimize the development of new infections. IV administration sets used to deliver blood and blood products are changed after each unit is administered. Administration sets to deliver lipids and TPN are often changed every 4 hours, whereas administration sets for maintenance fluids may be changed every 72 hours. It is important to follow institutional policies. All IV bags, bottles, and administration sets should be labeled with the date, time, and nurse's initials of the set change. Wearing gloves is not required for maintenance of routine infusion. Topical antibiotics may promote fungal infections and antimicrobial resistance. A peripheral line that is infusing should not need an anticoagulant to maintain patency.

[Jkov05]

TYSM

[nguyenhoanhat]

Excellent