A nurse is collecting data about an IV infusion site on an infant’s left hand.
Which of the following findings should the nurse identify as an indication of an infiltration?
Edema in the palm of the hand.
Absence of blanching at the insertion site.
Warmth around the insertion site.
Blood in the IV tubing.
The Correct Answer is A
Choice A rationale
Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.
Choice B rationale
Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.
Choice C rationale
Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.
Choice D rationale
Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Feeding an infant with spina bifida through an NG tube may not be necessary unless the child has specific feeding difficulties or other health issues. Spina bifida does not typically affect a child’s ability to eat or swallow.
Choice B rationale
Placing an infant with spina bifida in a prone position can help protect and care for the lesion on their back. It can also help prevent pressure sores and promote comfort.
Choice C rationale
Covering the infant’s lesion with a dry cloth is not typically recommended. The lesion should be kept clean and moist to promote healing and prevent infection.
Choice D rationale
While physical therapy and exercises can be beneficial for children with spina bifida, performing range-of-motion exercises to the infant’s hips may not be necessary unless specifically recommended by a healthcare provider.
Correct Answer is C
Explanation
Choice A rationale
While facial paralysis is a serious condition, it is not typically associated with a cleft palate.
Choice B rationale
Ear infections are a common complication of a cleft palate, but they are not typically a sign of an immediate, serious problem.
Choice C rationale
Increased intracranial pressure is not a common complication of a cleft palate, but it is a serious condition that requires immediate medical attention.
Choice D rationale
Drooling is common in children with a cleft palate and is not typically a sign of a serious problem.
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