A nurse is preparing to administer a prescribed dose of intravenous (IV) ondansetron to a client who is recovering from a laparoscopic cholecystectomy and reporting nausea. The client has a peripheral saline lock in place on the right forearm. Arrange the following steps for administering the IV push medication in the correct sequence.
- 1Clean the injection port of the peripheral saline lock with an antimicrobial swab.
- 2Attach a syringe filled with normal saline and flush the intravenous catheter.
- 3Attach the syringe containing ondansetron and administer the medication over the prescribed time.
- 4Attach a new syringe filled with normal saline and flush the intravenous catheter again.
- 5Clamp the extension tubing of the saline lock and remove the syringe.
Answer
The correct sequence for administering an IV push medication via a saline lock is to clean the port, flush with saline to check patency, administer the medication, flush again with saline to clear the line, and finally clamp the tubing.
The standard evidence-based protocol for administering an IV push medication into a peripheral saline lock is often remembered by the acronym SAS: Saline, Administer, Saline. First, the nurse must always maintain asepsis by cleaning the access port. Second, a normal saline flush is used to assess the patency of the intravenous site and ensure the fluid flows easily without causing swelling or pain. Third, the medication is pushed over the recommended time. Fourth, a second normal saline flush is administered to push the remaining medication in the extension tubing into the client's bloodstream. Finally, the tubing is clamped to maintain positive pressure and prevent blood reflux, which could cause a clot and subsequent loss of the IV access.
Step-by-Step Solution
Key Concept
Safe administration of intravenous push medications through a saline lock using the Saline-Administer-Saline (SAS) protocol.