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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.
B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.
C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.
D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.
Correct Answer is A
Explanation
A. Initiates speech rarely: This is a negative symptom of schizophrenia, where the individual may exhibit a lack of motivation or interest in social interaction, leading to reduced speech or verbal communication. Negative symptoms refer to the absence or decrease of normal functioning or behaviors, such as lack of speech, emotional expression, or motivation.
B. Has a preoccupation with religious thoughts: This is more of a positive symptom, potentially indicating delusions or hallucinations. Positive symptoms involve the presence of abnormal thoughts or behaviors.
C. Mimics the nurse's movements: This behavior, called echopraxia, is a positive symptom of schizophrenia, which involves involuntary imitation of another person's movements.
D. Smells odors that don't exist: This is a hallucination, which is a positive symptom of schizophrenia. Hallucinations are sensory perceptions without external stimuli, such as hearing voices or smelling things that aren’t there.
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