During a clinical rotation on an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool, blanched and slightly swollen. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?
Infiltration
Local inflammation
Thrombophlebitis
Phlebitis
The Correct Answer is A
A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.
B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.
C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.
D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. One of the significant changes that occur with aging is a decline in kidney function. This includes a decrease in renal blood flow, glomerular filtration rate (GFR), and the ability of the kidneys to concentrate urine. These changes can impair the body's ability to conserve water and maintain electrolyte balance, increasing the risk of dehydration.
A. As individuals age, there is actually a decrease in the percentage of body water relative to lean body mass. This is because aging is associated with an increase in adipose tissue and a decrease in muscle mass, which affects the overall body composition.
C Saliva production typically decreases with age, rather than increases. Reduced saliva production can contribute to dry mouth and may affect hydration status indirectly, but it is not a primary factor in increasing dehydration risk in older adults.
D. While changes in blood pressure can occur with aging, such as an increase in systolic blood pressure due to arterial stiffening, this does not directly contribute to an increased risk of dehydration. Blood pressure changes are more related to cardiovascular health rather than fluid balance.
Correct Answer is ["1.5"]
Explanation
Volume to administer (mL) = Dose ordered (mg) / Concentration of drug (mg/mL).
For a dose of 15 mg and a concentration of 10 mg/mL, the calculation would be 15 mg / 10 mg/mL = 1.5 mL.
Therefore, the nurse should administer 1.5 mL of morphine injection.
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