A nurse is caring for a school-age child who is receiving a continuous IV infusion through the right antecubital vein. Which of the following findings should the nurse recognize as a complication of IV therapy?
Capillary refill less than 2 seconds
Bilateral brachial pulses +3
Blood return from IV site catheter
Dark streak at the vein of the insertion site
The Correct Answer is D
A. Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion. This finding does not suggest a complication of IV therapy and reflects proper circulation in the extremity.
B. Bilateral brachial pulses +3: Strong, equal pulses in both arms indicate normal arterial blood flow. This is not indicative of IV complications and shows the limb is well perfused.
C. Blood return from IV site catheter: Blood return from the IV catheter confirms proper placement within the vein. This is an expected finding and does not signal a complication.
D. Dark streak at the vein of the insertion site: A dark streak along the vein suggests infiltration, phlebitis, or early thrombophlebitis. This indicates a complication of IV therapy and requires immediate assessment, site removal or rotation, and appropriate interventions to prevent further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Observe the client's ability to keep their elbows extended when using the crutches: The elbows should be slightly flexed, not fully extended, when using crutches. Observing for elbow extension is incorrect and could indicate improper technique. Proper elbow positioning is assessed as part of gait evaluation rather than as a standalone measure.
B. Instruct the client to lean forward when using the crutches: Leaning forward places excessive pressure on the axillae and increases the risk of nerve injury. Clients should maintain an upright posture while using crutches, so this instruction is unsafe and should not be included in care planning.
C. Observe the client's gait pattern when using the crutches: Observing the gait pattern allows the nurse to assess how the client distributes weight, coordinates movements, and uses the crutches safely. This assessment is essential prior to planning care and interventions, ensuring that the client can ambulate safely and independently.
D. Ensure the client's weight is placed on their axilla area when using the crutches: Weight should be supported by the hands and arms, not the axillae, to prevent nerve damage. Ensuring proper weight distribution is part of teaching and assessment, but placing weight on the axillae is incorrect and unsafe.
Correct Answer is C
Explanation
A. Withdraw dose of regular insulin: Withdrawing the regular insulin dose is performed after the air has been injected into both vials and the NPH insulin has been drawn up if using the “clear before cloudy” technique. Doing this first would risk disrupting the proper sequence and potentially contaminating the insulin.
B. Inject air into the vial of regular insulin: Air must be injected into the regular insulin vial before withdrawing the medication, but this step is performed after first injecting air into the NPH vial according to the standard procedure for mixing insulins. Starting with the regular insulin vial would not follow the recommended order.
C. Inject air into the vial of NPH insulin: Injecting air into the NPH insulin vial first is the initial step when preparing a mixed insulin dose. This step equalizes pressure inside the vial, allowing for easier withdrawal later, and follows the correct sequence of “air into cloudy first, then clear,” which prevents contamination of the regular insulin.
D. Withdraw dose of NPH insulin: Withdrawing NPH insulin is done after the regular insulin has been drawn into the syringe to maintain the correct “clear before cloudy” technique. Doing this first could result in accidental mixing or contamination of the regular insulin.
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