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 ["31"]
Explanation
Step 1 is to determine the total volume to be infused in minutes. This is done by multiplying the total volume by the drop factor: (1000 mL ÷ 480 min) × 15 gtt/mL = 31.25 gtt/min.
Correct Answer is C
Explanation
Choice A rationale:
Keeping the television on at all times can increase confusion and agitation in clients with Alzheimer’s disease due to the constant noise and changing images.
Choice B rationale:
Abstract pictures can be confusing and disorienting for clients with Alzheimer’s disease. It’s better to use simple, familiar images.
Choice C rationale:
Keeping familiar personal items in the client’s room can help orient the client to their surroundings and decrease confusion.
Choice D rationale:
Bright lighting can help reduce confusion and agitation in clients with Alzheimer’s disease by making the environment clear and easy to navigate.
So, the correct answer is C. Keep familiar personal items in client’s room.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.