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
This is a high level of potassium in the blood (the normal range is 3.5 to 5 mEq/L) and can be dangerous for the heart.
Triamterene is a potassium-sparing diuretic that prevents the body from losing too much potassium in the urine. It can cause hyperkalemia (high potassium), especially in people with kidney disease, diabetes, or severe illness. The nurse should check the potassium level before giving triamterene and hold the medication if it is above 5 mEq/L.
The other choices are incorrect because:
Choice A: Sodium 142 mEq/L.
This is a normal level of sodium in the blood (the normal range is 135 to 145 mEq/L) and does not require withholding triamterene. Triamterene can cause hyponatremia (low sodium) by increasing the excretion of sodium in the urine. The nurse should monitor the sodium level during triamterene therapy and report any signs of low sodium such as confusion, weakness, or seizures.
Choice B: BUN 16 mg/dL.
This is a normal level of blood urea nitrogen (BUN) in the blood (normal range is 7 to 20 mg/dL) and does not require withholding
triamterene. BUN is a measure of kidney function and can be elevated in kidney disease or dehydration. Triamterene can cause an increase in BUN by reducing the blood flow to the kidneys or by interacting with other medications that affect the kidneys. The nurse should monitor the BUN level during triamterene therapy and report any signs of kidney impairment such as decreased urine output, swelling, or nausea. •
Choice D: Albumin 4 g/dL.
This is a normal level of albumin in the blood (the normal range is 3.4 to 5.4 g/dL) and does not require withholding triamterene. Albumin is a protein that helps maintain fluid balance and transport substances in the blood. Triamterene does not affect albumin levels directly, but it can cause fluid loss or retention that may alter albumin levels indirectly. The nurse should monitor the albumin level during triamterene therapy and report any signs of fluid imbalance such as weight changes, edema, or shortness of breath.
Correct Answer is C
Explanation
A therapeutic effect of naloxone is the reversal of opioid-induced respiratory depression, which is one of the most dangerous complications of opioid overdose. Naloxone works by binding to opioid receptors, displacing opioids, and restoring normal respiratory drive. An increase in respiratory rate after administration indicates that naloxone is effective.
Choice A is wrong because decreased blood pressure is not a therapeutic effect of naloxone.
In fact, naloxone can cause hypertension (high blood pressure) as a side effect due to opioid withdrawal.
Choice B is wrong because decreased nausea is not a therapeutic effect of naloxone. Nausea is a common side effect of morphine, but naloxone does not affect it directly.
Naloxone can actually cause nausea and vomiting as a side effect due to opioid withdrawal.
Choice D is wrong because increased pain relief is not a therapeutic effect of naloxone.
Pain relief is a desired effect of morphine, but naloxone antagonizes it by blocking the opioid receptors.
Naloxone can cause pain and discomfort as a side effect due to opioid withdrawal.
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