Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Reddish streak proximal to the insertion site

Skin is pale and taut

The vein is firm and cord-like

IV fluid leaking from insertion site

Warmth at the insertion site

Answer and Explanation

Correct Answer : B,D,E

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.

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Correct Answer is A

Explanation

A. Serum potassium 3.2 mEq/L: A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac arrhythmias and muscle weakness. This condition requires prompt correction and collaboration with the healthcare provider before surgery to avoid intraoperative and postoperative complications.
B. Pulse rate 65 bpm: A pulse rate of 65 bpm is within the normal range (60-100 bpm). While it should be monitored, it does not require immediate intervention or collaboration with the healthcare provider before surgery.
C. Hematocrit 36%: A hematocrit level of 36% is within the lower end of the normal range (35-45% for women). This does not indicate an immediate concern that requires prompt collaboration with the healthcare provider.
D. Blood pressure 144/82 mmHg: Although this blood pressure reading is slightly elevated, it is not uncommon and can be managed perioperatively. It does not require immediate intervention before surgery.

A. Discard the container of formula every 12 hours B. Irrigate the tube with sterile water before administering medications C. Measure & record the residual volume after each feeding D. Keep head of bed elevated 30 degrees

Correct Answer is D

Explanation

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

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Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

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