A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Apply pressure to the IV site.

Elevate the extremity.

Slow the infusion rate.

Flush the IV catheter.

Answer and Explanation

The Correct Answer is B

This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.

Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.

Pressure can also obstruct blood flow and cause thrombophlebitis.

Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.

Slowing the infusion rate can also delay the delivery of medication or fluid to the client.

Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.

Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.

Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.

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Correct Answer is B

Explanation

Albumin is a protein that helps maintain fluid balance in the body by drawing water into the blood vessels. Albumin infusion can increase the blood volume and blood pressure in patients who are in shock due to fluid loss or sepsis.

Choice A is wrong because albumin infusion does not decrease protein levels in the body.

Albumin is a protein itself and adding it to the blood increases the protein concentration.

Choice C is wrong because oxygen saturation of 96% is normal and does not indicate any improvement or deterioration in the patient’s condition.

Choice D is wrong because PaCO2 of 30 mm Hg is low and indicates respiratory alkalosis, which can be caused by hyperventilation, fever, or anxiety. Albumin infusion does not affect PaCO2 levels directly.

A. Tinnitus. B. Hypotension. C. Hypokalemia. D. Bradycardia.

Correct Answer is B

Explanation

Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that is used to treat high blood pressure and heart failure. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart. However, one of the common side effects of lisinopril is hypotension, which means low blood pressure. Hypotension can cause dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position. Therefore, the nurse should monitor the client’s blood pressure when administering lisinopril and report any signs of hypotension to the doctor.

Choice A is wrong because tinnitus, which means ringing or buzzing in the ears, is not a common or serious side effect of lisinopril.

Tinnitus can be caused by other factors such as ear infections, loud noises, or medications such as aspirin or antibiotics.

Choice C is wrong because hypokalemia, which means low potassium levels in the blood, is not a common or serious side effect of lisinopril. In fact, lisinopril can cause hyperkalemia, which means high potassium levels in the blood, especially in patients with kidney problems or diabetes. Hyperkalemia can cause irregular heartbeats, muscle weakness, or numbness. Therefore, the nurse should monitor the client’s potassium levels when administering lisinopril and avoid giving potassium supplements or salt substitutes that contain potassium.

Choice D is wrong because bradycardia, which means slow heart rate, is not a common or serious side effect of lisinopril.

Lisinopril does not affect the heart rate directly, but it can lower the blood pressure and improve the heart function.

Bradycardia can be caused by other factors such as heart block, sinus node dysfunction, or medications such as beta blockers or calcium channel blockers.

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A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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