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 B

Explanation

A. “This medication will darken the color of my eyes.” is incorrect. Timolol is a nonselective beta-blocker used to reduce intraocular pressure in glaucoma. It does not typically cause eye color changes.

B. "I should check my heart rate while taking this medication." is correct. Timolol can cause systemic side effects such as bradycardia, so the client should monitor their heart rate while taking the medication.

C. "I should take a zinc supplement while taking this medication." is incorrect. Zinc supplementation is not related to the use of timolol.

D. “This medication will dilate my eyes." is incorrect. Timolol works by decreasing aqueous humor production, reducing intraocular pressure, and does not cause dilation of the eyes. Medications like atropine are used for pupil dilation.

A. Members of a health care team can share a computer password. B. Information regarding client health can be e-mailed if encrypted. C. A client is restricted from accessing his own medical records. D. Unwanted printed health information can be discarded in a trash can.

Correct Answer is B

Explanation

A. Members of a health care team can share a computer password.: This is incorrect. Passwords should never be shared, as doing so can compromise the confidentiality of client information. Each team member should have their own secure login and password.

B. Information regarding client health can be e-mailed if encrypted.: This is correct. According to HIPAA guidelines, it is permissible to email client health information if the email is encrypted and appropriate security measures are taken.

C. A client is restricted from accessing his own medical records.: This is incorrect. Clients have the right to access their own medical records under the Health Insurance Portability and Accountability Act (HIPAA..

D. Unwanted printed health information can be discarded in a trash can.: This is incorrect. Printed health information should be shredded, not simply discarded in the trash, to ensure confidentiality is maintained.

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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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