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 B
Explanation
A. Laissez-faire leadership style: A laissez-faire leadership style generally involves being permissive or non-directive, which is not typically associated with perpetrators of child abuse. Instead, abusive caregivers often have controlling or rigid parenting styles.
B. Rigid expectations of behavior: This is characteristic of many perpetrators of child abuse. They may have unrealistic or excessively strict expectations for their children's behavior, which can lead to frustration, anger, and, ultimately, abusive behaviors when those expectations are not met.
C. Self-blame for financial problems: While perpetrators of child abuse may experience stress due to financial issues, self-blame is not a defining characteristic. The stress from financial problems can contribute to abusive behaviors, but it is not the key factor.
D. High self-esteem: Perpetrators of child abuse typically have low self-esteem and may feel inadequate as parents. High self-esteem is not generally a characteristic of individuals who abuse children. Instead, feelings of powerlessness or frustration often contribute to abusive behavior.
Correct Answer is B
Explanation
A. "Your baby needs to suck on a pacifier" is not necessarily the best advice for this situation. While pacifiers can help some babies self-soothe, crying is often a sign of an unmet need, and further assessment is needed to determine the cause of the crying. Offering a pacifier without addressing other potential causes might overlook the root issue.
B. "Swaddling your baby snugly in a blanket might help soothe her" is correct. Swaddling can help calm a newborn by providing a sense of security and warmth, mimicking the conditions of the womb. It is a common technique used to soothe babies.
C. "Breastfed babies are usually fussy from swallowing too much air during feedings" is incorrect. While some babies may have mild gas or discomfort from swallowing air, excessive crying is not typically due to this alone, especially if the baby has been fed properly and burped.
D. "Breastfed babies often need to be supplemented with formula" is not appropriate. While some breastfeeding difficulties can occur, advising formula supplementation without further investigation could undermine the breastfeeding process and should only be suggested after careful assessment and if truly necessary.
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