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 D

Explanation

This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.

Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.

Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.

Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.

The client should maintain a normal sodium intake and drink enough fluids while taking lithium.

Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.

Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.

Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.

A. Bradycardia. B. Red man syndrome. C. Hypotension. D. Hypoglycemia.

Correct Answer is C

Explanation

Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.

Choice Ais wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.

Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.

Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.

Choice Dis wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.

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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

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