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 B
Explanation
Colesevelam is a bile acid sequestrant that lowers cholesterol by binding to bile acids in the intestine and preventing their reabsorption into the bloodstream. Some possible explanations for the other choices are:
Choice A. Chlorpromazine is wrong because it is an antipsychotic medication that has no effect on cholesterol levels.
Choice C. Colchicine is wrong because it is an anti-inflammatory drug that is used to treat gout and other inflammatory conditions, not high cholesterol.
Choice D. Cimetidine is wrong because it is a histamine H2 receptor antagonist that reduces stomach acid production and is used to treat ulcers and gastroesophageal reflux disease (GERD), not high cholesterol.
Normal ranges for cholesterol levels vary depending on the type of cholesterol and the risk factors of the individual, but generally, total cholesterol should be less than 200 mg/dL, LDL cholesterol should be less than 100 mg/dL, HDL cholesterol should be more than 40 mg/dL for men and 50 mg/dL for women, and triglycerides should be less than 150 mg/dL.
Correct Answer is B
Explanation
This is because TPN solutions are concentrated and can cause thrombosis of peripheral veins, so a central venous catheter is usually required. TPN should only be used when the intestine is unavailable or unable to absorb nutrients.
Choice A is wrong because a midline catheter is a type of peripheral catheter that can only be used for solutions with low or moderate osmolarity, not for TPN.
Choice C is wrong because subcutaneous administration is not a route for delivering TPN, which requires intravenous infusion.
Choice D is wrong because intraosseous administration is an emergency route for delivering fluids and drugs when intravenous access is not available, not for TPN.
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