Difficulty: Medium
Average Score: 90%
Simulated
A nurse is preparing to administer an antibiotic via intermittent IV bolus to a client who is already receiving an infusion of 0.9% sodium chloride at 100 mL/hr. Which of the following actions should the nurse take?
Correct answer
B
Rationale
The correct answer is B: Hang the secondary infusion higher than the primary IV infusion. This is to ensure that the antibiotic is infused first and at a faster rate than the maintenance fluid, preventing dilution of the antibiotic. Placing the secondary infusion higher allows gravity to push the antibiotic into the bloodstream before the maintenance fluid. Having another nurse verify the medication (choice A) is a good practice but not directly related to the administration process. Disconnecting the primary IV infusion (choice C) would interrupt the maintenance fluid, causing potential harm to the client. Flushing the IV site with sterile water (choice D) is not necessary in this case and could introduce contaminants.