A nurse is monitoring an intravenous infusion for a client who is dehydrated. The nurse should discontinue the IV for which of the following findings?
Serous drainage at the catheter insertion site
Small air bubble noted in the tubing
Blood return noted in the tubing
Blanched skin at the catheter insertion site
The Correct Answer is D
Choice A reason: Serous drainage at the insertion site may indicate mild irritation but does not require discontinuation unless accompanied by signs of infection or infiltration.
Choice B reason: A small air bubble in the tubing is generally harmless and does not require discontinuation. Large air bubbles pose a risk of air embolism, but small ones are typically absorbed without issue.
Choice C reason: Blood return in the tubing indicates that the IV catheter is correctly placed in the vein. This is a normal finding and does not require discontinuation.
Choice D reason: Blanched skin at the insertion site indicates infiltration, meaning IV fluid is leaking into surrounding tissue rather than the vein. This can cause tissue damage and requires immediate discontinuation of the IV to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A decrease in blood pressure is not characteristic of autonomic dysreflexia. Instead, autonomic dysreflexia typically causes a sudden and severe increase in blood pressure due to sympathetic nervous system overactivity triggered by stimuli below the level of injury. This option is incorrect.
Choice B reason: An increase in heart rate is not typical of autonomic dysreflexia. In fact, bradycardia (decreased heart rate) often occurs due to parasympathetic compensation in response to hypertension. Therefore, this option is incorrect.
Choice C reason: Eye twitching is not a recognized symptom of autonomic dysreflexia. The hallmark symptoms include severe hypertension, pounding headache, flushing, sweating above the level of injury, and nasal congestion. This option is incorrect.
Choice D reason: A sudden, severe headache is a hallmark symptom of autonomic dysreflexia. It results from acute hypertension caused by noxious stimuli such as bladder distention, fecal impaction, or skin irritation below the level of injury. This makes option D the correct answer.
Correct Answer is C
Explanation
Choice A reason: Hydrogen peroxide has limited effectiveness against bloodborne pathogens and is not the recommended agent for cleaning blood-contaminated surfaces. It may disinfect minor wounds but is not suitable for environmental cleaning of biohazard spills.
Choice B reason: Isopropyl alcohol is effective against many bacteria and viruses but is not recommended for cleaning large blood spills. Alcohol evaporates quickly and does not reliably inactivate all bloodborne pathogens such as hepatitis B or HIV when used on contaminated surfaces.
Choice C reason: Chlorine bleach is the recommended agent for cleaning surfaces contaminated with blood. A diluted bleach solution (usually 1:10 ratio) effectively kills bloodborne pathogens, including hepatitis B, hepatitis C, and HIV. It is widely used in healthcare settings for environmental decontamination.
Choice D reason: Chlorhexidine is an antiseptic used for skin preparation and wound cleansing. It is not appropriate for cleaning environmental surfaces contaminated with blood. Its use is limited to patient care, not environmental disinfection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.