A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter.
Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?.
"There's blood backing up my baby's IV tubing.”.
"There's a long red streak up my baby's arm.”.
"The tape is coming off the IV needle.”.
"My baby's fingers are looking swollen.”. .
The Correct Answer is D
Choice A rationale:
Blood backing up in the IV tubing indicates a problem with the IV line, not necessarily infiltration.
Choice B rationale:
A long red streak up the arm could indicate phlebitis, not infiltration.
Choice C rationale:
Loose tape could cause the IV needle to dislodge, but it doesn’t directly indicate infiltration.
Choice D rationale:
Swelling around the IV site is a common sign of infiltration.
So, the correct answer is D. “My baby’s fingers are looking swollen.”.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Blistering around the insertion site is not a common sign of phlebitis. It could indicate a more severe complication like extravasation or infiltration.
Choice B rationale:
Streak formation along the vein is a classic sign of phlebitis. It indicates inflammation and possible infection.
Choice C rationale:
Erythema at the insertion site is another common sign of phlebitis. It indicates inflammation.
Choice D rationale:
Warmth at the insertion site is also a common sign of phlebitis. It is caused by increased blood flow to the area due to inflammation. So, the correct answers are B, C, and D.
Correct Answer is B
Explanation
Choice A rationale:
Pseudoparkinsonism mimics the symptoms of Parkinson’s disease but is not typically characterized by choreiform movements, lip smacking, and spastic facial distortions.
Choice B rationale:
Tardive dyskinesia, a potential side effect of long-term use of chlorpromazine, is characterized by involuntary movements such as lip smacking and facial distortions.
Choice C rationale:
Akathisia is characterized by a sense of restlessness and a compulsion to move, not typically by the symptoms described.
Choice D rationale:
Dystonia involves involuntary muscle contractions and distortions but not typically the specific symptoms described.
So, the correct answer is B.
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