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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 B

Explanation

A. "Hold your breath for 6 seconds after inhaling the medication." – The correct recommendation is to hold the breath for at least 10 seconds to allow maximum medication absorption in the lungs.

B. "Inhale the medication deeply for 5 seconds." – A slow, deep inhalation (3-5 seconds) allows the medication to reach the lower airways effectively.

C. "Do not shake the medication in the inhaler." – Most metered-dose inhalers (MDIs) need to be shaken before use to ensure proper mixing of medication. Exceptions include dry powder inhalers (DPIs), which should not be shaken.

D. "Hold the inhaler 3 inches away from your mouth." – The correct distance is 1 to 2 inches (2-4 cm) from the mouth, or the mouthpiece can be placed directly into the mouth with lips sealed around it.

A. "Picture yourself in one of your favorite places." B. "Choose a word to help focus your attention. C. "Quickly inhale deeply and hold your breath for 30 seconds. D. "Plan for 1 hour of meditation for each session."

Correct Answer is B

Explanation

A. "Picture yourself in one of your favorite places." This statement is related to visualization, which is a different technique, not specifically meditation.

B. "Choose a word to help focus your attention." Mantra meditation involves repeating a word or phrase to enhance focus and promote relaxation.

C. "Quickly inhale deeply and hold your breath for 30 seconds." Holding the breath for 30 seconds can increase anxiety rather than reduce it. Meditation encourages slow, deep breathing, not breath-holding.

D. "Plan for 1 hour of meditation for each session." Meditation can be beneficial even if done for a few minutes. For beginners, shorter sessions (e.g., 5–10 minutes) are recommended.

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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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