The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:
flush the catheter with normal saline prior to and after medications.
secure the IV catheter to the extremity.
assess IV site frequently throughout the shift.
prevent contamination during the catheter insertion.
The Correct Answer is C
C. Regular assessment of the IV site is crucial to detect early signs of infiltration. Signs of infiltration include swelling, coolness, pain, or blanching around the insertion site. Assessing the site allows nurses to intervene promptly if infiltration occurs, preventing further complications such as tissue damage or fluid overload.
A. Flushing the IV catheter with normal saline helps to maintain patency and prevent blockage of the catheter. It also ensures that medications are effectively delivered into the bloodstream. While this action is important for maintaining the function of the IV catheter, it primarily addresses patency rather than preventing infiltration directly.
B. Securing the IV catheter to the extremity with a securement device (such as tape or a transparent dressing) helps prevent accidental dislodgement or movement of the catheter. This reduces the risk of
mechanical irritation at the insertion site, which can contribute to infiltration. Proper securement also ensures that the catheter remains in place during movement or patient activities.
D. Proper technique during catheter insertion helps reduce the risk of infection and subsequent complications, but it also indirectly contributes to preventing infiltration. Contamination during insertion can lead to inflammation or infection at the site, which may increase the risk of infiltration due to compromised tissue integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.
B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.
C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.
E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.
D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.
Correct Answer is ["A","B","E"]
Explanation
A. This is located on the lateral side of the thigh. It is a commonly used site for infants, toddlers, and young children, as well as adults who require large-volume injections.
B. This site is located on the hip or gluteal region. It is considered one of the safest and least painful sites for intramuscular injections in adults. It is also used when the volume of medication is larger or when the dorsogluteal site is contraindicated.
E. This site is located on the upper arm, specifically the lateral aspect. It is commonly used for vaccines and medications that require smaller volumes in adults and older children.
C. There is no specific muscle called the "rectus lateralis." It seems to be a combination of the rectus femoris (a muscle in the quadriceps group of the thigh) and the vastus lateralis. However, neither "rectus lateralis" nor "rectus femoris" is commonly used as a distinct injection site in clinical practice.
D. This site is located on the buttocks. Historically, it was a commonly used site for intramuscular injections, but it has fallen out of favor due to the potential risk of injury to the sciatic nerve and superior gluteal artery.
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