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. "Sit back down for a few minutes when this occurs." B. "Take a daily potassium supplement." C. "Restrict your daily fluid intake." D. "Discontinue this medication if this occurs again."

Correct Answer is A

Explanation

A. "Sit back down for a few minutes when this occurs.": This is correct. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effect. The client should be advised to sit down to prevent falls and allow the body to adjust.

B. "Take a daily potassium supplement.": This is incorrect. ACE inhibitors can increase potassium levels, and taking a potassium supplement without a healthcare provider’s recommendation may lead to hyperkalemia, a dangerous condition.

C. "Restrict your daily fluid intake.": This is incorrect. Dehydration can exacerbate hypotension, so it is not recommended to restrict fluid intake without further instructions from the provider.

D. "Discontinue this medication if this occurs again.": This is incorrect. The client should not discontinue medication without first consulting their healthcare provider. The healthcare provider may adjust the dosage or provide alternative recommendations to manage the side effects.

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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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