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.
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Related Questions
Correct Answer is B
Explanation
A. Removing personal protective equipment (PPE. after leaving the room is incorrect because it should always be done before leaving the client's room to ensure the nurse does not accidentally spread the infection. Proper removal of PPE is crucial to preventing transmission.
B. Wearing a gown when assisting the client with personal hygiene is correct. MRSA is typically spread through direct contact, so wearing a gown when providing personal care (e.g., assisting with hygiene. helps prevent the spread of MRSA. Additionally, gloves and other PPE should also be worn.
C. Negative air pressure is typically required for airborne precautions, such as for clients with tuberculosis, but not for MRSA, which is transmitted via contact. Therefore, this is not necessary for MRSA care.
D. Restricting the client's visitors is not necessary unless the client has an infection that requires isolation precautions beyond what is standard for MRSA. MRSA can be controlled with contact precautions, and visitor restrictions are generally not part of standard MRSA isolation.
Correct Answer is A
Explanation
A. Write the information at an 8th-grade reading level.: Health literacy is a key consideration when developing educational materials for the general public. Writing at an 8th-grade reading level ensures the content is accessible and understandable to a wide audience. This increases the likelihood that the target population will comprehend and retain the information.
B. Explain medical terminology using basic, one-syllable words.: While medical terms should be simplified, using only one-syllable words may result in oversimplification and miscommunication. Clear explanations should be provided in layman's terms, but not necessarily using only one-syllable words.
C. Use a 12-point font size.: A 12-point font size is a reasonable choice for readability, but 14-point or larger is often recommended for easier reading, especially for older adults or those with vision impairments.
D. Present information from complex to simple.: It is generally more effective to start with simple, basic concepts and build up to more complex information. Presenting information in a logical, structured manner—starting from the basics—will help the reader better understand the material.
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