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

Lithium can cause hyponatremia by increasing the secretion of antidiuretic hormone and reducing the renal clearance of sodium.

Strenuous exercise can also cause hyponatremia by increasing sweat loss and fluid intake. Therefore, a client who is taking lithium and starting a new exercise program is at risk of developing hyponatremia.

Choice A is wrong because hypomagnesemia is not a common side effect of lithium or exercise.

Choice B is wrong because hypocalcemia is not a common side effect of lithium or exercise.

Choice D is wrong because hypokalemia is not a common side effect of lithium or exercise.

However, lithium can interact with some diuretics that can cause hypokalemia, so the client should avoid taking these drugs without consulting their doctor. Normal ranges for electrolytes are:

Sodium: 135-145 mmol/L

Magnesium: 0.7-1.1 mmol/L

Calcium: 2.1-2.6 mmol/L

Potassium: 3.5-5.0 mmol/L

A. I should stay upright for at least 15 minutes after taking this medication. B. I should take an antacid with this medication to prevent stomach upset. C. I should take this medication with 8 ounces of milk. D. I should notify my provider if my stools turn black.

Correct Answer is A

Explanation

The client should stay upright for at least 15 minutes after taking ferrous gluconate to prevent oesophagal irritation. Choice B is wrong because taking an antacid with ferrous gluconate can decrease its absorption and effectiveness.

Choice C is wrong because taking ferrous gluconate with milk can also reduce its absorption and cause gastrointestinal distress.

Choice D is wrong because black stools are a common and harmless side effect of ferrous gluconate and do not indicate a need to notify the provider. Ferrous gluconate is an iron supplement used to treat or prevent iron deficiency anaemia, a condition where the body does not have enough red blood cells to carry oxygen to the tissues.

Iron is an essential component of haemoglobin, the protein that carries oxygen in the blood.

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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 caring for a client who is taking lithium and reports starting a new exercise program. The nurse should assess the client for which of the following electrolyte imbalances?

Correct Answer is C

Explanation

A nurse is teaching a client who has a prescription for ferrous gluconate. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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