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."

"My baby's fingers are looking swollen."

"There's a long red streak up my baby's arm."

"The tape is coming off the IV needle."

Answer and Explanation

The Correct Answer is B

B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.

A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.

C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.

D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D. Numbness and tingling of the hands and feet can indicate peripheral neuropathy, a known adverse effect of nitrofurantoin. It's essential for the nurse to recognize and communicate the potential seriousness of these symptoms to the client.

A. Numbness and tingling are not typically related to hydration status. While adequate hydration is important for overall health, it does not directly prevent numbness and tingling caused by medication side effects.

B. Symptoms like urinary frequency, burning, and dysuria are common symptoms of a urinary tract infection, not indicators of the medication working.

C Numbness and tingling of the hands and feet can be indicative of peripheral neuropathy, which is a potential adverse reaction to nitrofurantoin. While not all cases are severe, it's crucial to assess the severity and duration of these symptoms and notify the healthcare provider.

A. Administer the medication using a filter needle. B. Break the ampule by bending the top to the side. C. Flick the bottom of the ampule several times. D. Withdraw medication from the center of the ampule. E. None F. None

Correct Answer is A

Explanation

A. Using a filter needle is indeed a recommended practice when withdrawing medication from an ampule. This is because filter needles are designed to prevent glass particles from being drawn into the syringe after breaking the ampule.

B. Ampules should not be bent to open them. The proper method involves using a gauze or an ampule opener to snap the neck of the ampule away from the body. Bending the ampule can lead to shards of glass, risking injury to the nurse or contamination of the medication.

C. The ampule should be tapped gently to ensure all medication is in the lower portion before opening.

D. Withdrawing medication from the center of the ampule is the correct action because it ensures that the needle does not touch the broken glass edges, which could contaminate the medication or dull the needle.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is taking nitrofurantoin for a urinary tract infection voices a concern to the clinic nurse about experiencing numbness and tingling of the hands and feet. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is preparing to administer an IM injection to a client using a medication from an ampule. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is collecting data on a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?

A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

For a patient who is experiencing an ECV excess, the nurse plans to determine the fluid status. The best way for the nurse to determine the fluid balance for the patient is to:

A nurse is assisting in the plan of care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate?

A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)