A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?

Choice A Reason:

Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.

Choice B Reason:

Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.

Choice C Reason:

Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.

Choice D Reason:

Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.

Choice A Reason:
Isopropyl alcohol is the appropriate cleaning agent. While alcohol can be used as a disinfectant for some purposes, it might not be as effective as bleach against bloodborne pathogens like HIV. Bleach is generally recommended for disinfection in this context.
Choice B Reason:
Bleach is recommendable. Bleach is effective in disinfecting surfaces contaminated with bloodborne pathogens, including HIV. It's recommended for cleaning and disinfecting areas contaminated with blood as it can effectively kill many pathogens, including viruses like HIV. The standard recommendation is to create a solution of bleach and water to clean surfaces contaminated with blood.
Choice C Reason:
Hydrogen peroxide is not recommendable. Hydrogen peroxide has some disinfectant properties, but bleach is more effective against bloodborne pathogens like HIV when used to clean contaminated surfaces.
Choice D Reason:
Chlorhexidine is not appropriate. Chlorhexidine is an antiseptic commonly used for skin disinfection before procedures. While it's effective for certain purposes, it's not typically recommended for disinfecting surfaces contaminated with bloodborne pathogens like HIV. Bleach is the preferred agent in such cases.