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 A
Explanation
Choice A rationale
Lethargy in a child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt could indicate a serious problem such as shunt malfunction or infection, and should be the priority.
Choice B rationale
A respiratory rate of 20/min is within the normal range for a 4-year-old child and is not typically a cause for concern.
Choice C rationale
Lying flat on the unaffected side is not typically a cause for concern following ventriculoperitoneal shunt surgery.
Choice D rationale
A urine output of 50 mL in 2 hr is within the normal range for a 4-year-old child and is not typically a cause for concern.
Correct Answer is C
Explanation
Choice A rationale
The ventrogluteal site is not typically used for immunizations in infants. This site is often used in older children and adults, but it is not the preferred site for infants due to their small muscle mass.
Choice B rationale
The deltoid site is not typically used for immunizations in infants. This site is often used in older children and adults, but it is not the preferred site for infants due to their small muscle mass.
Choice C rationale
The vastus lateralis is the preferred site for administering immunizations in infants. This muscle is located in the thigh and is large enough to accommodate the injection. It is also away from major nerves and blood vessels, making it a safe site for injections.
Choice D rationale
The dorsogluteal site is not recommended for immunizations in any age group. This site has a number of large blood vessels and nerves, as well as a layer of fat, which can make injections less effective and potentially harmful.
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