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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Stating that palliative care is only for clients with a terminal illness is incorrect. Palliative care is designed for clients with serious, chronic, or life-threatening illnesses and focuses on symptom management and quality of life, regardless of prognosis.

B. Limiting palliative care to those with 6 months or less to live is incorrect. This definition applies to hospice care, not palliative care. Palliative care can be provided alongside curative treatments at any stage of illness.

C. Including restriction of nutritional support is incorrect. Palliative care emphasizes comfort and symptom relief, including providing adequate nutrition and hydration as appropriate for the client’s needs and wishes.

D. Enhancing quality of life by promoting comfort is correct. Palliative care aims to relieve symptoms such as pain, nausea, and fatigue while supporting the client’s emotional, psychological, and spiritual well-being.

A. Tinnitus B. Hyperglycemia C. Hypertension D. Hematuria

Correct Answer is C

Explanation

A. Tinnitus is not typically associated with the ingestion of tyramine-rich foods while on tranylcypromine.

B. Hyperglycemia is not a common adverse effect related to tyramine interaction with tranylcypromine.

C. Hypertension is correct. Ingesting tyramine-rich foods (such as aged cheese, cured meats, and fermented foods) while taking tranylcypromine, a monoamine oxidase inhibitor (MAOI), can cause a hypertensive crisis. Tyramine is normally broken down by monoamine oxidase (MAO), and inhibiting this enzyme with tranylcypromine can lead to a dangerous increase in blood pressure.

D. Hematuria is not a known adverse effect of tranylcypromine or the ingestion of tyramine-rich foods.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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