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 B

Explanation

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

Correct Answer is ["8"]

Explanation

Step 1 is: Calculate the total units of heparin in the bag, which is 25,000 units.

Step 2 is: Divide the total units by the total volume to find the units per mL, which is (25,000 units ÷ 250 mL) = 100 units/mL.

Step 3 is: Divide the desired units per hour by the units per mL to find the mL/hr, which is (800 units/hr ÷ 100 units/mL) = 8 mL/hr. So, the infusion pump rate should be set at 8 mL/hr.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

Correct Answer is ["8"]

Explanation

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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?