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 ["1"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 50 mcg
Available Concentration: 100 mcg/2 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (50 ÷ 100) × 2
Volume to administer = 0.5 × 2
Volume to administer = 1 mL
Correct Answer is A
Explanation
A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.
B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.
C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.
D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.
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