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 C

Explanation

A. Crush the medication and administer it through the tube: Crushing sustained-release medications can disrupt their intended release mechanism, leading to potential overdose or ineffective treatment.
B. Provide the medication orally for the client to swallow: This option is not suitable since the client has a gastrostomy tube, and oral administration is not appropriate.
C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration: This is the correct approach, as an elixir form of the medication would be appropriate for administration through the gastrostomy tube without altering its release properties.
D. Dissolve the medication in water and administer it through the tube: Dissolving sustained-release tablets can compromise their intended release mechanism, which may lead to complications.

A. Warfarin (Coumadin) B. Gabapentin (Neurontin) C. Xanax (Alprazolam) D. Atenolol (Tenormin)

Correct Answer is A

Explanation

A. Warfarin (Coumadin): This is the correct choice. Warfarin is an anticoagulant that increases the risk of bleeding during and after surgery. The surgeon needs to be notified to consider holding the medication and to adjust the surgical plan if necessary.
B. Gabapentin (Neurontin): While important for pain management, it does not significantly impact surgical procedures or bleeding risk.
C. Xanax (Alprazolam): This medication is a benzodiazepine used for anxiety, which might be relevant for preoperative anxiety but does not require immediate notification of the surgeon.
D. Atenolol (Tenormin): This beta-blocker is used for hypertension and heart conditions but does not require immediate notification of the surgeon unless there are specific cardiac concerns related to surgery.

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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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