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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mix the medications together and administer through the NG tube. Incorrect because medications should be given separately to prevent drug interactions and ensure each is fully delivered.
B. Crush the sublingual medication into powder form. Incorrect because sublingual medications are designed to be absorbed through the oral mucosa, not the gastrointestinal tract. Crushing them negates their intended action.
C. Dissolve crushed tablet medications in sterile water. Sterile water is preferred for dissolving medications because it reduces the risk of bacterial contamination and prevents potential drug interactions that may occur with other fluids.
D. Flush the tube with 5 mL saline between each medication. Incorrect because a minimum of 15-30 mL of water is recommended between medications to prevent tube blockage.
Correct Answer is D
Explanation
A. Provide the client with a referral to a support group. Not the first priority; occurs later in the grieving process.
B. Encourage the client to view the body of their partner. Only appropriate if the client wants to do so.
C. Reinforce the need for the client to build new relationships. Insensitive and premature during initial grief.
D. Encourage the client to share their thoughts and feelings. Therapeutic communication is the first step in grief support, allowing the client to process emotions.
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