A nurse is caring for a client who is receiving continuous IV fluid therapy and notes the skin is taught and blanched at the IV insertion site. Which of the following findings should the nurse expect?
Local infection
Thrombophlebitis
Venous air embolism
Infiltration
The Correct Answer is D
A. Local infection: Local infection at an IV site presents with redness, warmth, swelling, and sometimes purulent drainage. The skin may feel tender or painful, but blanching and tautness are not characteristic features of infection, making this less likely.
B. Thrombophlebitis: Thrombophlebitis involves inflammation of the vein, often with a palpable cord, redness, and warmth along the vein. Pain is common, but the skin usually does not appear blanched or tight, distinguishing it from the findings described in this client.
C. Venous air embolism: A venous air embolism is a rare but serious complication that occurs when air enters the venous system. Clinical manifestations typically include sudden dyspnea, chest pain, hypotension, and a mill-wheel murmur, rather than local skin changes at the IV site.
D. Infiltration: Infiltration occurs when IV fluid leaks into the surrounding tissue rather than the vein. Characteristic findings include taut, blanched, cool, and swollen skin at the insertion site. The nurse may also notice decreased or stopped flow from the IV, and the area may be tender. Prompt recognition and removal of the IV catheter are essential to prevent tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 25 mL/hr: Normal urine output is approximately 0.5 mL/kg/hr, which for most adults equates to at least 30 mL/hr. A urine output of 25 mL/hr is below expected postoperative levels and in a post-TURP client, decreased output could suggest clot retention or catheter blockage, which requires immediate assessment and intervention.
B. Pain of 8 on a scale of 0 to 10: Severe pain of 8/10 is not typical for a client 2 days post-TURP if the catheter and analgesics are managed appropriately. While mild discomfort or bladder spasms may occur, intense pain could indicate complications such as catheter obstruction, bladder spasms, or infection, necessitating prompt evaluation and intervention.
C. Dark red urine: Dark red urine, or gross hematuria, is abnormal and may indicate active bleeding from the surgical site. While some pink or light-red discoloration is expected post-TURP due to minor oozing, dark red urine suggests significant hemorrhage, which can lead to hypovolemia or clot retention and requires immediate attention.
D. Small clots with tissue in the urine: It is expected to see small clots and tissue fragments in the urine 1–3 days following a TURP. The resection of prostatic tissue creates raw surfaces that bleed slightly, and the indwelling catheter facilitates continuous bladder irrigation to prevent large clot formation. Presence of small clots and tissue debris in urine at this stage is a normal postoperative finding and indicates proper healing while avoiding significant hemorrhage.
Correct Answer is A
Explanation
A. Bulging anterior fontanel: A bulging anterior fontanel in a newborn can indicate increased intracranial pressure caused by conditions such as hydrocephalus, intracranial hemorrhage, or infection (e.g., meningitis). This finding is abnormal and requires prompt reporting to the healthcare provider for further assessment and intervention to prevent neurological compromise.
B. Flexed posture: A flexed posture is a normal finding in a 1-hour-old newborn. Newborns typically maintain flexion of the arms and legs due to intrauterine positioning and muscle tone. This posture is expected and indicates normal neuromuscular development.
C. Moro reflex present: The presence of the Moro reflex is a normal neurological finding in a healthy newborn. It demonstrates intact vestibular function and reflexive motor responses, which are expected within the first hours after birth.
D. Acrocyanosis: Acrocyanosis, or bluish discoloration of the hands and feet, is a common and normal finding in the first few hours after birth due to immature peripheral circulation. It usually resolves spontaneously as the newborn’s cardiovascular system stabilizes.
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