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 B

Explanation

A. Prolonged PT/INR. Prolonged PT/INR may occur due to liver dysfunction or vitamin K deficiency, but it is not a direct result of pancreatitis. In pancreatitis, the liver is usually functioning normally unless there is concurrent liver disease.
B. Elevated lipase. Elevated lipase is a hallmark laboratory finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly during episodes of pancreatitis, making it a key indicator in diagnosing the condition.
C. Elevated ammonia. Elevated ammonia levels are more commonly associated with liver dysfunction, such as hepatic encephalopathy, rather than pancreatitis. Pancreatitis primarily affects the digestive system, not the liver directly.
D. Decreased albumin. Decreased albumin can be seen in various conditions, including liver disease and malnutrition, but it is not a specific finding for pancreatitis. In acute pancreatitis, albumin levels may not be significantly affected, while chronic pancreatitis can lead to malabsorption and potentially lower albumin levels over time.

A. Neck pain B. Temporary memory loss C. Voice alteration D. Tingling of the scalp

Correct Answer is B

Explanation

A. Neck pain can occur in some patients following electroconvulsive therapy (ECT) due to muscle tension or positioning during the procedure. However, it is not a common or expected adverse reaction associated with ECT, so it is not the primary concern to address.
B. Temporary memory loss is a well-documented adverse reaction following ECT. Patients may experience difficulties with short-term memory, particularly related to events that occurred around the time of the treatment. This memory loss is usually temporary, but it can be distressing for some individuals.
C. Voice alteration is not typically associated with ECT. Although some patients may experience hoarseness or changes in vocal quality due to intubation or anesthesia, this is not a direct result of ECT itself and is not commonly mentioned in the context of ECT side effects.
D. Tingling of the scalp is not a recognized adverse reaction to ECT. Patients may experience various sensations, but tingling is not a common or documented response. The primary focus should be on more significant effects, such as temporary memory loss and potential confusion immediately following the treatment.

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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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