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."
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To administer a dose of 250 mg of amoxicillin when only 125 mg tablets are available, the nurse would need to give two tablets. This is because each tablet contains 125 mg, and two tablets would equal the required dose of 250 mg
Correct Answer is A
Explanation
A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.
B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.
C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.
D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.
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