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 A

Explanation

Hyponatremia is a condition where the sodium level in the blood is too low, which can cause confusion, lethargy, seizures, and coma. A hypertonic solution is a fluid that has a higher concentration of solutes than the blood, which can help raise the sodium level and reduce the brain swelling caused by hyponatremia. Therefore, improved cognition indicates that the treatment is effective.

Choice B. Cardiac arrhythmias absent.

Cardiac arrhythmias are not a common symptom of hyponatremia unless it is severe or rapid in onset.

Therefore, their absence does not necessarily indicate that the treatment is effective.

Choice C. Decreased vomiting.

Vomiting can be a cause or a consequence of hyponatremia, depending on the underlying condition.

Decreased vomiting may indicate that the patient is less nauseated, but it does not reflect the sodium level or the brain status.

Choice D. Absent Chvostek’s sign.

Chvostek’s sign is a facial twitching that occurs when tapping on the cheek, which indicates hypocalcemia (low calcium level).

It is not related to hyponatremia or hypertonic solution.

Normal ranges for sodium are 135 to 145 mEq/L and for calcium are 8.5 to 10.5 mg/dL.

A. The client tests negative for HIV. B. The client has a negative sputum culture. C. The client’s liver function test results are within the expected reference range. D. The client has a positive purified protein derivative test.

Correct Answer is B

Explanation

The client has a negative sputum culture. This indicates that the client is adhering to the medication regimen because a negative sputum culture means that the client is no longer infectious and has cleared the tuberculosis bacteria from their lungs.

Choice A is wrong because testing negative for HIV does not indicate that the client is adhering to the medication regimen for tuberculosis. HIV testing is not related to tuberculosis treatment.

Choice C is wrong because having a positive purified protein derivative test does not indicate that the client is adhering to the medication regimen for tuberculosis.

A positive PPD test means that the client has been exposed to tuberculosis, but it does not indicate whether the client has an active or latent infection. Choice D is wrong because having liver function test results within the expected reference range does not indicate that the client is adhering to the medication regimen for tuberculosis.

Liver function tests are used to monitor for possible adverse effects of isoniazid and rifampin, which can cause hepatotoxicity, but they do not reflect the effectiveness of the treatment.

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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 has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective?

Correct Answer is A

Explanation

A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the following outcomes indicates that the client is adhering to the medication regimen?

Correct Answer is B

Explanation

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