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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D,A,E,C,B

Explanation

The nurse should first stop the infusion (D) to prevent further infiltration of the vesicant solution. Next, the nurse should attach a syringe to the catheter (E) to prepare for aspiration.

Following this, the nurse should aspirate the solution from the catheter (C) to remove as much of the vesicant as possible. After aspiration, the nurse should disconnect the tubing from the catheter (A), ensuring that no additional vesicant is administered. Finally, the nurse should remove the IV catheter (B) to prevent any further exposure to the vesicant.

A. Hyperactive bowel sounds B. Cerebral edema C. Hypertension D. Muscle weakness

Correct Answer is D

Explanation

D. Muscle weakness is a hallmark sign of hypokalemia. Potassium is crucial for proper muscle contraction, and low levels can impair muscle function. This weakness can affect skeletal muscles (resulting in fatigue, cramps, or generalized weakness) as well as smooth muscles (contributing to constipation or other gastrointestinal symptoms).

A. Hypokalemia is not typically associated with hyperactive bowel sounds.

B. Cerebral edema is not typically associated with hypokalemia. Instead, cerebral edema can occur with conditions such as hyponatremia (low sodium levels) or other metabolic disturbances.

C. Hypokalemia is more commonly associated with hypotension (low blood pressure) rather than hypertension. Low potassium levels can affect vascular smooth muscle tone, potentially leading to vasodilation and hypotension.

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The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D,A,E,C,B

Explanation

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Correct Answer is D

Explanation

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