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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Taking a high-ceiling diuretic predisposes this client to developing digoxin toxicity because it can cause hypokalemia (low blood potassium level), which increases the sensitivity of the heart to digoxin. Digoxin is a medicine that is used to treat heart failure or arrhythmias (abnormal heart rhythms) by increasing cardiac contractility and controlling the heart rate. Digoxin toxicity happens when there is too much digoxin in the body and it becomes harmful, causing symptoms such as nausea, vomiting, headache, confusion, vision disturbance, and irregular heartbeat.

Choice A is wrong because taking an HMG CoA reductase inhibitor (also called a statin) does not increase the risk of digoxin toxicity.

Statins are lipid-lowering medications used to prevent coronary heart disease by blocking an enzyme involved in cholesterol synthesis.

Statins do not affect the blood potassium level or the sensitivity of the heart to digoxin.

Choice B is wrong because having a 10-year history of COPD (chronic obstructive pulmonary disease) does not increase the risk of digoxin toxicity. COPD is a lung condition that causes breathing difficulties and chronic inflammation.

COPD does not affect the blood potassium level or the sensitivity of the heart to digoxin.

Choice D is wrong because having a prolapsed mitral valve does not increase the risk of digoxin toxicity.

A prolapsed mitral valve is a condition where the valve between the left atrium and left ventricle of the heart does not close properly, allowing some blood to leak back into the atrium.

A prolapsed mitral valve does not affect the blood potassium level or the sensitivity of the heart to digoxin.

A. St. John’s Wort. B. Black cohosh. C. Coenzyme Q. D. Ginger root.

Correct Answer is A

Explanation

The nurse should advise the client to avoid taking St. John’s Wort with sertraline because it can increase the risk of a rare but serious condition called serotonin syndrome. Serotonin syndrome can cause symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhoea.

Choice B. Black cohosh is wrong because it is a herbal supplement that is used to treat menopausal symptoms and has no known interaction with sertraline.

Choice C. Coenzyme Q is wrong because it is a natural substance that is involved in energy production and has no known interaction with sertraline.

Choice D. Ginger root is wrong because it is a spice that is used to treat nausea and has no known interaction with sertraline.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 digoxin to treat heart failure. Which of the following factors predisposes this client to developing digoxin toxicity?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking sertraline and reports a desire to begin taking supplements. Which of the following supplements should the nurse advise the client to avoid?

Correct Answer is A

Explanation

A nurse is caring for a client who is to receive potassium replacement. The provider’s prescription reads, “Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min.” For which of the following reasons should the nurse clarify this prescription with the provider?

A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?

A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following adverse effects?

A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?

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?

A nurse is caring for a client who has major depression and a new prescription for citalopram. Which of the following adverse effects is the priority for the nurse to report to the provider?

A nurse is teaching a client who has pernicious anemia to self-administer nasal cyanocobalamin. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has breast cancer and reports pain 1 hr after administration of prescribed morphine 10 mg IV. Which of the following medications should the nurse expect to administer?