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.

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Correct Answer is B

Explanation

B. One of the significant changes that occur with aging is a decline in kidney function. This includes a decrease in renal blood flow, glomerular filtration rate (GFR), and the ability of the kidneys to concentrate urine. These changes can impair the body's ability to conserve water and maintain electrolyte balance, increasing the risk of dehydration.

A. As individuals age, there is actually a decrease in the percentage of body water relative to lean body mass. This is because aging is associated with an increase in adipose tissue and a decrease in muscle mass, which affects the overall body composition.

C Saliva production typically decreases with age, rather than increases. Reduced saliva production can contribute to dry mouth and may affect hydration status indirectly, but it is not a primary factor in increasing dehydration risk in older adults.

D. While changes in blood pressure can occur with aging, such as an increase in systolic blood pressure due to arterial stiffening, this does not directly contribute to an increased risk of dehydration. Blood pressure changes are more related to cardiovascular health rather than fluid balance.

A. Sedation B. Urinary retention C. Hypertension D. Blurred vision

Correct Answer is D

Explanation

D. Blurred vision is a known adverse effect of metoclopramide. It can occur due to its effects on the central nervous system, including potential effects on visual processing. Patients should be informed about this potential side effect, and vision should be monitored periodically.

A. Metoclopramide can cause drowsiness or sedation, especially at higher doses or in susceptible individuals. Monitoring for sedation is important to ensure patient safety and adjust dosing as needed.

B. Urinary retention: Although less common, metoclopramide has been associated with urinary retention. Patients should be monitored for signs and symptoms of urinary difficulty or retention, especially if they have pre-existing urinary issues.

C. Hypertension: Metoclopramide can occasionally lead to an increase in blood pressure, particularly in patients who are predisposed to hypertension or have other cardiovascular risk factors. Blood pressure monitoring is important during treatment.

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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

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