A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?
Erythema
Edema
Blood
Pruritus
The Correct Answer is B
A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.
B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.
C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.
D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Insertion of a nasogastric tube: While informed consent is important for many procedures, the insertion of a nasogastric (NG) tube is generally considered a routine procedure that may not require formal informed consent unless specific complications or risks are involved.
B. Administration of an iron injection using Z-track technique: Informed consent is typically required for procedures with inherent risks or invasive elements, but routine administration of iron injections is not typically classified as needing informed consent, unless there are specific concerns.
C. Irrigation of a wound with antibiotic solution: Irrigation of a wound is typically a low-risk procedure, and although it is important to inform the client about the treatment, it generally does not require formal informed consent unless there are complications or risks involved.
D. Placement of a central venous catheter: Informed consent is required for the placement of a central venous catheter, as it is an invasive procedure with potential risks such as infection, bleeding, and damage to blood vessels. This procedure requires the nurse to obtain and document the client's consent before proceeding.
Correct Answer is B
Explanation
A. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.
B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.
D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.
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