A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions shouldthe nurse take?
A.
Use the injection port farthest from the IV catheter insertion site.
B.
Occlude the IV tubing above the injection port.
C.
Check for blood return after medication administration.
D.
Flush the IV tubing with a heparinized solution.
The correct answer and Explanation is :
The correct answer is B. Occlude the IV tubing above the injection port.
When administering an IV bolus through an existing continuous infusion line, it is crucial to occlude the IV tubing above the injection port to prevent the continuous IV fluid from mixing with the bolus during administration. This ensures the medication is delivered directly to the client without dilution or alteration, allowing for proper therapeutic effect. By occluding the tubing, the nurse creates a temporary block, preventing any backflow of the bolus medication and ensuring that it enters the circulation effectively.
Explanation of Other Options:
- A. Use the injection port farthest from the IV catheter insertion site: While using an injection port is standard practice, using the one farthest from the catheter is not recommended in this case. It’s more effective to use the port closest to the insertion site to ensure that the medication reaches the bloodstream faster and reduces the chance of the drug lingering in the tubing.
- C. Check for blood return after medication administration: While checking for blood return is a crucial step before starting any IV medication to ensure patency of the line, it should be done before administering the bolus, not after.
- D. Flush the IV tubing with a heparinized solution: Flushing the IV tubing with a heparinized solution is typically done for central lines to maintain patency and prevent clot formation. For peripheral lines or continuous infusions, a saline flush is more common. Heparin is usually unnecessary unless specifically indicated, and improper use could increase the risk of complications, like bleeding.
By occluding the IV tubing above the injection port, the nurse ensures proper administration of the albumin bolus while maintaining the integrity of the continuous infusion.