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A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

Dryness

Edema

Erythema

A distended vein

Answer and Explanation

The Correct Answer is B

A. Dryness – Infiltration leads to swelling and fluid accumulation, not dryness.

B. Edema – Infiltration occurs when IV fluids leak into surrounding tissue, causing swelling (edema).

C. Erythema – While redness (erythema) can indicate phlebitis, it is not a primary sign of infiltration.

D. A distended vein – A distended vein is more likely seen with fluid overload or thrombosis, not infiltration.

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Correct Answer is D

Explanation

A. "I think you will regret it if you don't have this surgery." – This is non-therapeutic and pressures the client rather than encouraging discussion.

B. "It's too late to cancel your cataract surgery." – This is false information; clients have the right to refuse treatment at any time.

C. "This surgery is painless, so you shouldn't worry." – This minimizes the client’s concerns and dismisses their feelings.

D. "Share with me more about the thoughts that are concerning you." – This therapeutic response encourages the client to express their concerns, allowing the nurse to address them appropriately.

A. Document shiny, taut skin as an expected finding. B. Perform palpation after auscultation. C. Listen for 1 min before documenting absent bowel sounds. D. Perform auscultation immediately after the client has consumed a meal.

Correct Answer is B

Explanation

A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.

B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.

C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.

D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.

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A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

Nursing Test Bank

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