The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:
every 5 hours
once per shift
hourly
once a day
The Correct Answer is C
C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.
A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.
B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.
D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Dextrose 10% in water is a solution that contains a high concentration of glucose (dextrose). Infusing D10W can lead to an increase in blood glucose levels, especially if the client's body cannot metabolize the glucose effectively (e.g., in diabetic patients or those with impaired glucose tolerance).
A. Dextrose 10% in water does not contain calcium. Hypercalcemia refers to elevated calcium levels in the blood, which can occur due to various causes such as hyperparathyroidism or excessive vitamin D intake, but not from D10W infusion.
C. Dextrose 10% in water is not used to treat hypovolemia (low blood volume). It is a solution primarily used to provide calories and prevent ketosis rather than to expand circulating blood volume.
D. Dextrose 10% in water does not contain potassium. Hypokalemia (low potassium levels) can occur due to various reasons such as diuretic use, gastrointestinal losses, or inadequate intake, but it is not directly related to D10W infusion.
Correct Answer is D
Explanation
D. Blurred vision is a known adverse effect of metoclopramide. It can occur due to its effects on the central nervous system, including potential effects on visual processing. Patients should be informed about this potential side effect, and vision should be monitored periodically.
A. Metoclopramide can cause drowsiness or sedation, especially at higher doses or in susceptible individuals. Monitoring for sedation is important to ensure patient safety and adjust dosing as needed.
B. Urinary retention: Although less common, metoclopramide has been associated with urinary retention. Patients should be monitored for signs and symptoms of urinary difficulty or retention, especially if they have pre-existing urinary issues.
C. Hypertension: Metoclopramide can occasionally lead to an increase in blood pressure, particularly in patients who are predisposed to hypertension or have other cardiovascular risk factors. Blood pressure monitoring is important during treatment.
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