A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter.
Which of the following observations at the IV site should the nurse identify as signs of infiltration?

Skin blanching

Bleeding

Purulent exudate

Warmth .

Answer and Explanation

The Correct Answer is A

Infiltration of an IV site is characterized by skin blanching, which is a whitening or lightening of the skin. This occurs when IV fluids or medications leak into the surrounding tissue from the vein. The area may also be cool to touch and swollen.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.

Choice B rationale

The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.

Choice C rationale

The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.

Choice D rationale

Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.

A. Determine the reasons why the client is refusing to use the incentive spirometer. B. Document the client’s refusal to participate in health restorative activities. C. Administer a pain medication to the client.

Correct Answer is A

Explanation

The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.

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A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter. Which of the following observations at the IV site should the nurse identify as signs of infiltration?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?

Correct Answer is A

Explanation

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A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter.
Which of the following observations at the IV site should the nurse identify as signs of infiltration?