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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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Apply firm, direct pressure to the catheter insertion site is the best first action because it directly addresses the immediate concern of bleeding, helping to prevent excessive blood loss and stabilize the client.

Assess vital signs and assess for signs of hypovolemia is the best next action, as the client's increasing heart rate and decreasing blood pressure suggest potential blood loss, which could lead to hypovolemic shock.

Incorrect answers;

Lowering the head of the bed and assessing circulation (B in i) is important but should follow bleeding control.

Increasing IV fluids (C in i) may be necessary but should be done based on provider orders after controlling bleeding.

Preparing for fluid resuscitation (B in ii) is relevant but is not the first step; monitoring vitals is a more immediate priority.

Notifying the provider (C in ii) is crucial but should occur after assessing the client's status to provide accurate information.

A. Ask the client to tilt their head back when swallowing. B. Have the client sit upright for 1 hr following meals. C. Administer liquids to the client using a syringe. D. Allow the client to rest for 10 min prior to eating.

Correct Answer is B

Explanation

A. Ask the client to tilt their head back when swallowing. Tilting the head back increases the risk of aspiration by opening the airway. Instead, the "chin tuck" method is recommended.

B. Have the client sit upright for 1 hr following meals. Sitting upright for an extended period reduces the risk of aspiration by allowing gravity to assist in digestion.

C. Administer liquids to the client using a syringe. Using a syringe can increase the risk of aspiration and does not allow the client to control swallowing.

D. Allow the client to rest for 10 min prior to eating. While rest may help conserve energy, it is not a priority intervention for dysphagia management.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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