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Question 861Question →

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a peripheral IV line. The current continuous IV fluid infusing is incompatible with the prescribed IV push medication. In what order should the nurse perform the following actions to safely administer the medication? Arrange the actions in the correct sequence.

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Answer

Stop the infusion/clamp tubing, scrub the port, flush with saline, administer the medication, flush with saline at the medication rate, and restart the infusion.
When administering an IV push medication through a line with an incompatible continuous infusion, the nurse must first stop the infusion and clamp the line to prevent mixing. The lowest port is used and scrubbed to maintain asepsis. A preliminary saline flush clears the incompatible fluid from the tubing. The medication is then administered at the prescribed rate, followed by a post-administration saline flush. Crucially, the post-flush must be pushed at the same rate as the medication to avoid rapidly infusing the medication still residing in the tubing. Finally, the primary infusion is safely restarted.

Step-by-Step Solution

1
Stop the continuous IV infusion and clamp the primary tubing.
The flow of the incompatible fluid is halted.
Prevents the mixing of the incompatible medication and the continuous IV fluid, which could cause precipitation.
2
Scrub the injection port closest to the client with an antiseptic swab.
The access point is sanitized.
Maintains asepsis and prevents line-associated bloodstream infections.
3
Flush the IV line with 10 mL of 0.9% sodium chloride.
The line is cleared of the incompatible continuous IV fluid.
Creates a physical fluid barrier between the incompatible solutions.
4
Administer the prescribed IV push medication over the recommended duration.
The medication is delivered safely into the bloodstream.
Administering at the correct rate prevents adverse physiological reactions like speed shock.
5
Flush the IV line again with 10 mL of 0.9% sodium chloride at the same rate as the medication.
Residual medication is safely cleared from the tubing.
Ensures the full dose reaches the client. Flushing at the medication's rate prevents pushing residual medication in the tubing too rapidly.
6
Unclamp the primary tubing and resume the continuous IV fluid infusion.
The continuous fluid therapy is restored.
Maintains the prescribed fluid or medication regimen after the IV push medication is successfully given.

Key Concept

Safe administration of an IV push medication through a line with an incompatible continuous infusion requires stopping the infusion and using the SAS (Saline, Administer, Saline) method at the lowest port.
Question 862Question →

A nurse is caring for a client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence is to first stop the transfusion, then replace the IV tubing to infuse normal saline, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood product to the lab.
In a suspected transfusion reaction, the priority sequence follows the principle of halting the trigger, maintaining physiological support, assessing the damage, and then communicating findings. Stopping the blood is always the first action. Maintaining IV access with new tubing prevents infusing residual blood while keeping a line open for emergency drugs. Assessing the client provides the necessary clinical picture before notifying the provider. Finally, returning the materials allows the laboratory to investigate the cause.

Step-by-Step Solution

1
Stop the transfusion immediately.
Prevents further administration of incompatible blood.
Halting the offending agent is the primary physiological adaptation intervention in any hypersensitivity or hemolytic reaction.
2
Replace the IV tubing and infuse 0.9% sodium chloride.
Maintains IV access without pushing more blood into the client.
IV access is critical for resuscitation. Using the existing tubing would inappropriately flush incompatible red blood cells into the client's circulation.
3
Assess the client's vital signs and respiratory status.
Provides current physiological baseline data.
Accurate clinical data is necessary to guide medical treatment and properly inform the healthcare provider of the client's status.
4
Notify the healthcare provider and the blood bank.
Initiates collaborative medical management.
The provider will prescribe emergency medications (e.g., epinephrine, diuretics, fluids), and the blood bank must begin an investigation into the reaction.
5
Return the blood bag, tags, and tubing to the blood bank.
Allows for laboratory analysis of the reaction.
This is standard post-reaction protocol to determine the exact cause of the hemolytic or allergic event.

Key Concept

Acute Hemolytic Transfusion Reaction Management
Estimated Time:1m 30s
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