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 D

Explanation

A. Kleihauer-Betke test. This test is used to detect fetal-maternal hemorrhage by identifying fetal red blood cells in maternal circulation. It is not related to a nonreactive NST, which indicates the need for further fetal well-being assessment rather than checking for fetal-maternal bleeding.
B. Amnioinfusion. This procedure involves infusing fluid into the amniotic sac to relieve umbilical cord compression or dilute meconium-stained amniotic fluid. It is not an appropriate intervention for a nonreactive NST, as it does not assess fetal oxygenation or reactivity.
C. Administration of terbutaline. Terbutaline is a tocolytic used to relax the uterus and prevent preterm labor. It is not indicated for a nonreactive NST, as the concern in this scenario is fetal well-being rather than uterine activity.
D. Contraction stress test. A nonreactive NST means that the fetal heart rate does not demonstrate adequate accelerations, which can indicate potential fetal hypoxia. A contraction stress test is performed next to evaluate how the fetal heart rate responds to contractions, helping determine if the fetus can tolerate labor.

A. Tell the client to leave the group if they cannot contribute. B. Allow the client extra time to think of a response. C. Appoint the client to lead the discussion. D. Ask other group members to limit the number of responses

Correct Answer is B

Explanation

A. Tell the client to leave the group if they cannot contribute. Forcing a client to leave due to silence is inappropriate and can increase feelings of isolation and anxiety. Clients should be encouraged to participate at their own pace.
B. Allow the client extra time to think of a response. Some clients may need more time to process thoughts before speaking. Allowing extra time provides a supportive environment and respects the client’s comfort level in participation.
C. Appoint the client to lead the discussion. Assigning a leadership role to a silent client may increase anxiety and discourage participation rather than help them feel included. Participation should be encouraged but not forced.
D. Ask other group members to limit the number of responses. Restricting other members' participation does not address the silent client’s needs and may disrupt group dynamics. Instead, creating an inclusive and supportive environment is key to fostering engagement.

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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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