A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter.
Which of the following observations at the IV site should the nurse identify as signs of infiltration?

 

Choice A rationale

Assisting the patient to a left side-lying position with the right knee flexed is often used for rectal examinations or administering enemas, but it does not directly address the issue of a large amount of fecal material in the colon.

Choice B rationale

Preparing the patient for a chest x-ray would not be beneficial in this situation. A chest x-ray would not provide further information about the fecal material in the colon.

Choice C rationale

Administering a cleansing enema can help to remove the fecal material from the colon. This is a common treatment for fecal impaction.

Choice D rationale

Performing a manual digital examination of the patient’s rectum can help to assess the amount of fecal material present, but it would not alleviate the patient’s abdominal pain or remove the fecal material.

Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.

Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.

Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.

Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.

Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.

Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.

Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.

Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.