A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

The client's left arm is cool to the touch.

The client's left arm is swollen.

There is a red streak up the client's left arm.

The client reports tenderness at the IV insertion site.

The client reports cramping above the insertion site.

Answer and Explanation

Correct Answer : A,B

A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The client's vital signs indicate worsening hypotension (BP decreased from 90/50 mmHg to 76/45 mmHg) and tachycardia (HR increased from 118 to 121 bpm), suggesting hypovolemia, possibly due to gastrointestinal (GI) bleeding from a suspected peptic ulcer (positive H. pylori test and hemoccult-positive stool). First Action – Obtain IV Access: The client is at risk for hypovolemic shock, so establishing IV access is the priority to administer fluids or blood products if needed. Second Action – Place the client in a supine position with feet elevated:This helps improve perfusion to vital organs by increasing venous return and cardiac output.

Rationale for Incorrect Options:

Rechecking oxygen saturation is unnecessary at this moment because SpO₂ is already stable at 98%.

Calling the surgical team STAT is premature; stabilization of the client’s circulation should occur first before proceeding with the endoscopy.

A. Obtain a large-bore IV catheter. B. Explain to the client that transfusion reactions are not serious. C. Ensure two nurses confirm the information on the blood label. D. Ensure the transfusion tubing is flushed with dextrose 5% in water. E. Witness the client signing consent for transfusion.

Correct Answer is ["A","C","E"]

Explanation

A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.

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A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

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Explanation

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