Select the port farthest from the insertion site.
The port selected should be the one closest to the IV insertion site for three reasons. Less dilution of the medication will occur, the medication will move into the vascular system more readily, and it is easier to assess if catheter placement is correct by blood return.
Ensure that the tubing above the injection port is patent.
Tubing above the port should be occluded by pinching the tubing gently, stopping the IV solution flow while the medication is pushed.
Time the medication administration with a watch. (Correct Answer)
Using a watch to time the administration ensures safe medication infusion. Ideally, the watch should have a second hand or digital readout. Many medications that are prescribed as IV push or bolus need to be given slowly over several minutes.
Explain the procedure to the client after completion.
Client teaching should be done prior to administration regarding purpose of the medication and adverse effects to report.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is an Evaluation Question.
For this type of question, you are looking for something correct/incorrect, right/wrong, safe/unsafe, or true/false. Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
- Correct action when administering IV push medication.
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Evaluation questions. Move to Step 5.
STEP 5: What is the outcome of each of the remaining answer choices?
Evaluate the outcome(s)
1. Select the port farthest from the insertion site. This will delay the action of the medication getting to the client. The nurse should choose the closest port to administer the IV medication. Eliminate.
2. Ensure that the tubing above the injection port is patent. The nurse should determine patency of the IV line prior to administering medications, not just above the injection port but below as well. Eliminate.
3. Time the medication administration with a watch. This action will allow the nurse to administer the medication over the allotted time frame and not administer too quickly.
4. Explain the procedure to the client after completion. All procedures should be explained to the client prior to performing them. Eliminate.
Select the best choice:
Is #3 the correct answer? Yes. Timing the administration of all medications is important to give the medication safely.
Does #3 make sense? Yes. This is the correct action when administering an IV push medication.
