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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Methimazole is an antithyroid medication that blocks the thyroid from making thyroid hormones. It is used to treat hyperthyroidism caused by Graves’ disease, which is an autoimmune disorder that stimulates the thyroid gland to produce excess hormones. After taking methimazole for 2 months, the client should expect to see a reduction in the symptoms of hyperthyroidism, such as weight loss, increased pulse rate, and heat intolerance. Increased sleeping is a sign of improved thyroid function, as hyperthyroidism can cause insomnia and restlessness.
Choice A is wrong because weight loss is a symptom of hyperthyroidism, not a result of methimazole treatment. Methimazole should lower the thyroid hormone levels and help the client gain weight.
Choice B is wrong because an increase in pulse rate is also a symptom of hyperthyroidism, not a result of methimazole treatment. Methimazole should lower the heart rate and blood pressure by reducing thyroid hormone levels.
Choice D is wrong because warmer skin is another symptom of hyperthyroidism, not a result of methimazole treatment. Methimazole should improve the client’s heat tolerance and make the skin cooler and less sweaty.
Correct Answer is D
Explanation
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
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