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 C
Explanation
A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.
B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.
C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.
D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points
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.
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