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. "I can have two glasses of wine with dinner." While moderate alcohol consumption may be acceptable, guidelines typically recommend limiting alcohol intake to one drink per day for women. Two glasses of wine may exceed this recommendation, and excessive alcohol can contribute to higher blood pressure.
B. "I will set my blood pressure goal at 130 over 84." The target blood pressure for individuals with mild hypertension is usually less than 130/80 mmHg. Setting a goal of 130/84 does not meet the recommended guidelines for managing hypertension effectively.
C. "I should exercise for 15 minutes two times per week!" While any exercise is beneficial, the general recommendation for adults is to engage in at least 150 minutes of moderate-intensity aerobic activity each week, which translates to about 30 minutes on most days. Exercising only two times per week for 15 minutes is insufficient for achieving cardiovascular health and blood pressure management.
D. "I should decrease my salt intake to 2 grams per day." Decreasing salt intake to 2 grams per day indicates an understanding of dietary recommendations for managing hypertension. The American Heart Association recommends limiting sodium intake to no more than 2,300 mg per day, and further reduction to 1,500 mg may be beneficial for those with hypertension. Reducing salt can help lower blood pressure effectively.

A. "Anticipate that the insulin glargine will peak in 3 hours." B. "Draw up the insulin lispro and insulin glargine in separate syringes." C. "Expect insulin glargine to be cloudy." D. "Take an extra dose of insulin lispro prior to aerobic exercise."

Correct Answer is B

Explanation

A. "Anticipate that the insulin glargine will peak in 3 hours." Insulin glargine is a long-acting basal insulin with no pronounced peak. Instead, it provides a steady level of insulin over 24 hours, reducing the risk of hypoglycemia. Unlike short- or intermediate-acting insulins, it does not have a defined peak time.
B. "Draw up the insulin lispro and insulin glargine in separate syringes." Insulin glargine should never be mixed with other insulins in the same syringe, as it has a unique pH that can cause precipitation when combined. Insulin lispro, a rapid-acting insulin, can be mixed with some other insulins, but it must be drawn up separately from insulin glargine to maintain its stability and effectiveness.
C. "Expect insulin glargine to be cloudy." Insulin glargine is a clear solution. Cloudy insulins, such as NPH (neutral protamine Hagedorn), require gentle rolling before administration to mix the suspension evenly. If insulin glargine appears cloudy, it may be contaminated or compromised and should not be used.
D. "Take an extra dose of insulin lispro prior to aerobic exercise." Taking extra insulin lispro before exercise can increase the risk of hypoglycemia, as physical activity naturally lowers blood glucose levels. Clients with diabetes should monitor their blood glucose before, during, and after exercise and may need to adjust their carbohydrate intake rather than taking additional insulin.

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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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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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