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 C

Explanation

C. Dextrose 5% in water is a hypotonic solution that contains 5 grams of dextrose in each 100 mL of water. It provides free water without adding significant sodium, which helps to dilute the elevated sodium levels in hypernatremia. This solution is effective in correcting hypernatremia by promoting water movement from the intravascular space into the cells and extracellular space.

A. Albumin solutions are primarily used for volume expansion and to increase oncotic pressure in conditions like hypoalbuminemia or shock. They do not provide free water and are not typically used for treating hypernatremia.

B. Dextrose 10% in water is a hypertonic solution used primarily for providing calories and treating hypoglycemia. It does not correct hypernatremia because it does not significantly affect sodium levels or provide sufficient free water to dilute sodium.

D. Dextran 40 is a colloid solution that is used for volume expansion in hypovolemia or shock. It does not provide free water and is not indicated for correcting hypernatremia.

A. Select a 22-gauge needle for heparin administration. B. Insert the needle at a 90° angle. C. Massage the injection site after administering the heparin. D. Aspirate for a blood return prior to injecting the heparin.

Correct Answer is B

Explanation

B. Subcutaneous injections are generally administered at a 45° or 90° angle, depending on the amount of subcutaneous tissue present. In obese clients, there is typically more subcutaneous tissue, so inserting the needle at a 90° angle may be necessary to ensure proper medication absorption.

A. A smaller gauge needle (such as 25 or 26 gauge) is usually more appropriate for subcutaneous injections to minimize discomfort and tissue trauma, especially in obese clients where there is more subcutaneous tissue.

C. Massaging the injection site after administering heparin is not recommended. It can cause discomfort, bruising, and potentially alter the absorption rate of the medication. The injection site should be gently

pressed with a dry gauze pad after withdrawal of the needle to help disperse the medication and prevent leakage, but massaging should be avoided.

D. Aspiration is not necessary for subcutaneous injections. It is generally used for intramuscular injections to ensure the needle is not in a blood vessel, which is less of a concern for subcutaneous injections. The injection technique involves pinching the skin and injecting the medication into the subcutaneous tissue without aspirating.

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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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