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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Clozapine is an antipsychotic medication that is used to treat schizophrenia and other psychotic disorders. It works by affecting the balance of certain chemicals in the brain.
Choice A is wrong because clozapine can cause weight gain, not weight loss, in some people. This can increase the risk of diabetes, high cholesterol, and heart problems. The nurse should advise the client to monitor their weight regularly and to follow a healthy diet and exercise plan.
Choice B is wrong because ringing in the ears (tinnitus) is not an expected adverse effect of clozapine. However, clozapine can cause other ear problems, such as otitis media (middle ear infection) or otitis externa (outer ear infection). The nurse should instruct the client to report any ear pain, discharge, or hearing loss to their provider.
Choice D is wrong because diarrhoea is not a common adverse effect of clozapine. However, clozapine can cause constipation, which can be severe and lead to bowel obstruction or perforation. The nurse should advise the client to drink plenty of fluids, eat high-fibre foods, and use laxatives as prescribed by their provider.
Choice C is correct because fever is a serious adverse effect of clozapine that may indicate a life-threatening condition called
agranulocytosis. Agranulocytosis is a severe reduction in white blood cells that can impair the immune system and increase the risk of infections. The nurse should instruct the client to notify their provider immediately if they develop a fever or any signs of infection, such as sore throat, cough, or flu-like symptoms. The client should also have regular blood tests to monitor their white blood cell count while taking clozapine.
Correct Answer is C
Explanation
Atorvastatin is a medication that belongs to a group of drugs called statins. It is used to lower blood levels of “bad” cholesterol (low-density lipoprotein, or LDL), to increase levels of “good” cholesterol (high-density lipoprotein, or HDL), and to lower triglycerides (a type of fat in the blood). The treatment has been effective if the LDL level is reduced, as high LDL levels can increase the risk of heart disease and stroke. A normal range for LDL is less than 100 mg/dL.
Choice A is wrong because urine specific gravity is a measure of how concentrated the urine is, not how much cholesterol is in the blood. A normal range for urine specific gravity is 1.005 to 1.0304.
Choice B is wrong because BUN (blood urea nitrogen) is a measure of how well the kidneys are working, not how much cholesterol is in the blood. A normal range for BUN is 7 to 20 mg/dL.
Choice D is wrong because blood glucose is a measure of how much sugar is in the blood, not how much cholesterol is in the blood.
A normal range for blood glucose is 70 to 100 mg/dL.
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