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","E","F"]

Explanation

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

A. "My child still wets the bed at least two times per week." B. "My child continually asks me the same questions." C. "I have noticed that my child is withdrawn since we switched day care providers." D. "I have a difficult time getting my child to eat green vegetables."

Correct Answer is C

Explanation

A. "My child still wets the bed at least two times per week." Bedwetting (nocturnal enuresis) is common in young children, and while it can be concerning, it is not uncommon for a 4-year-old. Many children still experience bedwetting at this age, and it usually resolves over time.
B. "My child continually asks me the same questions." Continually asking the same questions can be typical for a 4-year-old, as children often seek clarification and reassurance through repetitive questioning. While it may be frustrating, it is generally not a sign of a serious issue.
C. "I have noticed that my child is withdrawn since we switched day care providers." Withdrawal can be a sign of emotional distress, anxiety, or adjustment issues related to the change in daycare. The nurse should further assess the child's emotional and behavioral responses to ensure they are receiving the appropriate support and intervention if needed.
D. "I have a difficult time getting my child to eat green vegetables." Getting the child to eat green vegetables is a common challenge among young children, as they often exhibit food preferences and may be picky eaters. While it is important to encourage healthy eating habits, this issue does not require immediate intervention compared to concerns about emotional withdrawal.

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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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Exhibits Which of the following findings requires further action by the nurse? Select all that apply.

Correct Answer is ["D","E","F"]

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Correct Answer is C

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