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A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

Dryness

Edema

Erythema

A distended vein

Answer and Explanation

The Correct Answer is B

A. Dryness – Infiltration leads to swelling and fluid accumulation, not dryness.

B. Edema – Infiltration occurs when IV fluids leak into surrounding tissue, causing swelling (edema).

C. Erythema – While redness (erythema) can indicate phlebitis, it is not a primary sign of infiltration.

D. A distended vein – A distended vein is more likely seen with fluid overload or thrombosis, not infiltration.

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Correct Answer is C

Explanation

A. Pull the fire alarm. While activating the alarm is crucial, the immediate priority is client safety, meaning evacuation comes first.

B. Close the fire doors. Closing doors helps contain the fire, but ensuring client safety is the priority.

C. Evacuate the room. According to the RACE (Rescue, Alarm, Contain, Extinguish) protocol, the first step is to Rescue clients in immediate danger, then pull the alarm.

D. Extinguish the fire. Attempting to put out the fire is only appropriate if the fire is small and manageable. If the fire is significant, evacuating clients takes precedence.

A. Carotid bruit B. Heart murmur C. Pulse deficit D. Bounding radial pulse

Correct Answer is C

Explanation

A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.

B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.

C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.

D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.

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A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

Nursing Test Bank

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