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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. “I will overarticulate words when speaking.": Overarticulating words can distort speech and make it more difficult for a client with hearing loss to understand. Clear, normal articulation combined with visual cues is more effective for communication.

B. “I will repeat words not heard by the client": Repeating words is useful, but it is a secondary strategy. Effective communication begins with proper positioning and visual cues, which enhance understanding before repetition is needed.

C. “I will speak in a loud voice when addressing the client.": Speaking louder does not necessarily improve comprehension and can distort speech. Many clients with hearing loss benefit more from clear, normal-volume speech and lip-reading rather than increased volume.

D. “I will face the client when speaking": Facing the client allows them to use visual cues, such as lip reading and facial expressions, which significantly improves understanding. This technique is the primary and most effective communication strategy for clients with hearing loss.

A. Presence of 50 mL/hr in the drainage chamber B. Tidaling occurs when the client is breathing C. Continuous bubbling in the water seal chamber D. Oxygen saturation of 92% on room air

Correct Answer is C

Explanation

A. Presence of 50 mL/hr in the drainage chamber: Some drainage after chest tube placement is expected. A rate of 50 mL/hr is within a typical range for postoperative monitoring, especially in the first 24 hours, and does not usually require immediate provider notification unless it increases significantly or becomes bloody.

B. Tidaling occurs when the client is breathing: Tidaling, or the rise and fall of fluid in the water seal chamber with respiration, indicates that the chest tube system is patent and functioning correctly. This is an expected finding and reflects normal intrathoracic pressure changes during breathing.

C. Continuous bubbling in the water seal chamber: Continuous bubbling in the water seal chamber suggests an air leak in the system. This is abnormal and requires provider notification because persistent air leaks can impair lung re-expansion, compromise respiratory function, and may indicate malfunction of the system or a worsening pneumothorax.

D. Oxygen saturation of 92% on room air: An oxygen saturation of 92% is slightly below normal but may be expected immediately postoperative or in clients with lung compromise. It requires monitoring and supplemental oxygen if needed, but it is not as urgent as a continuous air leak in the chest tube system.

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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?

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