A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Apply pressure to the IV site.

Elevate the extremity.

Slow the infusion rate.

Flush the IV catheter.

Answer and Explanation

The Correct Answer is B

This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.

Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.

Pressure can also obstruct blood flow and cause thrombophlebitis.

Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.

Slowing the infusion rate can also delay the delivery of medication or fluid to the client.

Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.

Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.

Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.

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Correct Answer is C

Explanation

Nitroglycerin transdermal patches are used to prevent episodes of angina (chest pain) in people who have coronary artery disease (narrowing of the blood vessels that supply blood to the heart). They work by relaxing the blood vessels so that the heart does not need to work as hard and therefore does not need as much oxygen.

Choice A is wrong because nitroglycerin transdermal patches cannot be used to treat an attack of angina once it has begun. They can only be used to prevent attacks of angina. If you have chest pain, you should use another form of nitroglycerin, such as sublingual tablets or spray.

Choice B is wrong because headache is a common side effect of nitroglycerin transdermal patches and does not mean that you should stop using them. However, you should tell your doctor if the headaches are severe or do not go away. You may also take acetaminophen to relieve the headache.

Choice D is wrong because you do not need to cover the patch with dry gauze when taking a shower. You may shower while you are wearing a nitroglycerin skin patch. If a patch loosens or falls off, replace it with a fresh one.

A. Oliguria. B. Nausea. C. Headaches. D. Weight gain.

Correct Answer is A

Explanation

Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.

One of the signs of fluid volume deficit is oliguria, which means low urine output.

Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.

Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.

Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.

Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.

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A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is assessing a client who is taking an osmotic laxative. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

Correct Answer is A

Explanation

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