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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","E"]

Explanation

A. External rotation of the hip involves rotating the thigh outward away from the midline of the body. This movement occurs in the hip joint. External rotation is a component of hip range of motion.

B. Extension of the hip involves moving the thigh backward, straightening the leg from a flexed position. This movement also occurs in the hip joint. Extension is part of the hip's range of motion.

C. Adduction of the hip involves moving the thigh toward or across the midline of the body. It brings the leg closer to the midline. Adduction is another movement that is part of the hip's range of motion.

E. Flexion of the hip involves bringing the thigh toward the abdomen or bending the leg. It is a movement where the angle between the thigh and the abdomen decreases. Flexion is a fundamental movement of the hip joint.

D. Supination is a movement primarily associated with the forearm and hand, involving turning the palm upward or facing forward. It is not a movement of the hip joint. Supination is not correct in the context of hip range of motion.

A. Monitoring intake and output B. Providing good mouth and skin care C. Obtaining daily weights D. Assessing level of consciousness E. Administering a loop diuretic

Correct Answer is ["A","B","C","D"]

Explanation

A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.

B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.

C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.

D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.

E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea

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The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

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