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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Isometric exercises typically involve pushing or pulling against a stationary object or surface. This action creates muscle tension without joint movement.

B. Using a trapeze involves lifting the body and is more related to mobility assistance rather than isometric exercise. It typically involves movement and is not considered an isometric exercise.

C. Brisk walking is a cardiovascular exercise that involves movement and does not focus on muscle contraction without movement. It improves cardiovascular fitness and endurance rather than strength through isometric contraction.

D. Active range of motion exercises involve moving joints through their full range of motion using muscle strength. This is different from isometric exercises, which involve static muscle contractions without joint movement.

A. has a high level of health literacy. B. wants to be discharged as soon as possible. C. has attended many years of school. D. recognizes a benefit in the knowledge.

Correct Answer is D

Explanation

D. When clients perceive that the knowledge or information being presented is beneficial to their health outcomes, they are more likely to be motivated to learn. Understanding how the knowledge can improve their health, manage their condition, or prevent complications provides intrinsic motivation to engage in learning activities.

A. While health literacy is important for understanding health information, having a high level of health literacy alone does not guarantee motivation to learn. Motivation to learn is more about personal engagement and perceived relevance of the information to one's own health and well-being.

B. While this may provide motivation for compliance with treatment plans or learning specific self-care tasks required for discharge, it does not necessarily translate to a strong motivation to learn beyond immediate needs related to discharge.

C. Formal education may contribute to overall cognitive abilities and learning skills, but it does not automatically translate into motivation to learn in a healthcare context. Motivation to learn is more about personal interest, perceived relevance, and understanding the benefits of acquiring new knowledge.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about isometric exercise. Which activity indicates that the client understands the teaching? The client:

Correct Answer is A

Explanation

The nurse understands that motivation to learn is strongest when the client:

Correct Answer is D

Explanation

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