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?

Skin blanching

Bleeding

Purulent exudate

Warmth .

Answer and Explanation

The Correct Answer is A

Infiltration of an IV site is characterized by skin blanching, which is a whitening or lightening of the skin. This occurs when IV fluids or medications leak into the surrounding tissue from the vein. The area may also be cool to touch and swollen.

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Correct Answer is C,A,D,B

Explanation

Choice A rationale

Injecting 5 units of air into the bottle of regular insulin is the second step in the procedure. This is done after injecting air into the NPH insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.

Choice B rationale

Withdrawing the correct dose of NPH insulin from the bottle is the last step in the procedure. This is done after withdrawing the regular insulin to prevent contamination of the regular insulin with the NPH insulin.

Choice C rationale

Injecting 10 units of air into the bottle of NPH insulin is the first step in the procedure. This is done before injecting air into the regular insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.

Choice D rationale

Withdrawing the correct dose of regular insulin from the bottle is the third step in the procedure. This is done after injecting air into the regular insulin bottle and before withdrawing the NPH insulin. The purpose of this step is to ensure that the correct dose of regular insulin is administered.

A. Hypertension B. Hypotension C. Tachycardia D. Bradycardia

Correct Answer is C

Explanation

Choice A rationale

Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.

Choice B rationale

Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.

Choice C rationale

Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.

Choice D rationale

Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. Determine the correct order of steps for this procedure.

Correct Answer is C,A,D,B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given. Heart rate of 110 bpm Complete the following sentence using the list of options. The patient exhibits symptoms of ________

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?