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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain written consent by the client for the placement of the restraints. It is not typically required to obtain written consent from the client for the use of restraints. However, consent may be necessary for treatment in general, depending on the facility's policies and state laws. Restraints are usually applied to ensure safety and must be justified based on the client's behavior.
B. Release the client's restraints every 4 hr. Restraints should be released more frequently, typically every 1 to 2 hours, to assess the client's safety and physical condition and to allow for movement, hydration, and toileting as appropriate.
C. Document the client's behavior leading to the initiation of the restraints. Documenting the client's behavior that necessitated the use of restraints is crucial for legal and ethical reasons. This documentation provides a clear rationale for the use of restraints and helps ensure compliance with facility policies and regulations.
D. Check the client's status every hour. The client's status should be checked more frequently than every hour. Regular monitoring is essential to ensure the client's safety, comfort, and physical well-being while in restraints. The nurse should assess the client every 15 to 30 minutes based on facility protocols.
Correct Answer is B
Explanation
A. Open the dampers of fireplaces. Keeping fireplace dampers open would allow contaminated outdoor air to enter the home, increasing exposure to harmful chemicals. During an outdoor chemical disaster, it is essential to seal the home as much as possible to prevent infiltration of toxic substances.
B. Cover heat registers with plastic and tape. Sealing heat registers helps prevent outside air from circulating into the home through ventilation systems. This precaution reduces exposure to airborne chemicals by limiting pathways for contamination. Creating an airtight environment is a key strategy in shelter-in-place recommendations during chemical disasters.
C. Exit the home as quickly as possible. Evacuating during an outdoor chemical disaster may increase the risk of exposure if toxic fumes are present. Authorities typically advise sheltering in place with sealed windows and doors unless an evacuation order is issued. Leaving should only occur when officials confirm that it is safe.
D. Turn on ceiling fans and air conditioners. Running ventilation systems like fans and air conditioners can draw in outside air, increasing exposure to hazardous chemicals. Instead, all air systems should be turned off to minimize circulation of contaminated air within the home.
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