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 A

Explanation

A. A negative pressure room is correct. Varicella zoster, which causes chickenpox, is an airborne virus. Therefore, airborne precautions are required, which include placing the client in a negative pressure room to prevent the spread of the virus to other areas of the facility.

B. Administering aspirin is incorrect. Aspirin should not be given to children or adolescents with varicella zoster due to the risk of Reye's syndrome. Instead, an antipyretic such as acetaminophen should be used to treat fever.

C. Contact precautions are not sufficient for varicella zoster, as the virus requires airborne precautions to prevent transmission through the air.

D. Having visitors remain at least 0.91 m (3 feet) away is incorrect. Airborne precautions require that visitors wear appropriate PPE, including respirators, and should not be restricted to 3 feet away. Ideally, visitors should wear full protective gear when entering the room.

A. Check the client's vital signs every 4 hr. B. Provide the client with high-calorie finger foods. C. Encourage the client to participate in group activities. D. Allow the client to establish his own schedule.

Correct Answer is B

Explanation

A. Check the client's vital signs every 4 hr.: Although monitoring vital signs is important, it is not the primary concern in acute mania unless the client is showing signs of physical distress (e.g., tachycardia, dehydration).

B. Provide the client with high-calorie finger foods.: This is correct. During acute mania, clients may have difficulty sitting down to eat, and high-calorie finger foods can help ensure the client gets adequate nutrition. These foods are easy to consume and provide the necessary calories.

C. Encourage the client to participate in group activities.: While socialization can be beneficial, group activities may overstimulate a client in acute mania and could lead to further agitation. It is better to encourage more structured and individual activities initially.

D. Allow the client to establish his own schedule.: Clients in acute mania may have poor judgment and impulsive behavior. Allowing them to establish their own schedule could lead to disorganized behavior. The nurse should offer structure to prevent this.

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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

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