A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter.
Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?.
"There's blood backing up my baby's IV tubing.”.
"There's a long red streak up my baby's arm.”.
"The tape is coming off the IV needle.”.
"My baby's fingers are looking swollen.”. .
The Correct Answer is D
Choice A rationale:
Blood backing up in the IV tubing indicates a problem with the IV line, not necessarily infiltration.
Choice B rationale:
A long red streak up the arm could indicate phlebitis, not infiltration.
Choice C rationale:
Loose tape could cause the IV needle to dislodge, but it doesn’t directly indicate infiltration.
Choice D rationale:
Swelling around the IV site is a common sign of infiltration.
So, the correct answer is D. “My baby’s fingers are looking swollen.”.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Antipsychotic medications can cause extrapyramidal symptoms, which include involuntary muscle contractions and tremors.
Choice B rationale:
Insulin, used to treat type 2 diabetes mellitus, does not typically cause extrapyramidal symptoms.
Choice C rationale:
Pancreatic enzymes, used to treat chronic pancreatitis, are not associated with extrapyramidal symptoms.
Choice D rationale:
Beta-adrenergic blockers, used to treat hypertension, do not typically cause extrapyramidal symptoms.
So, the correct answer is A, A client who has schizophrenia and is taking an antipsychotic medication.
Correct Answer is C
Explanation
Choice A rationale:
The client should maintain a normal fluid intake while taking lithium, not limit it to 800 ounces per day.
Choice B rationale:
Lithium can be taken with or without food. This instruction is not necessary.
Choice C rationale:
It can indeed take up to 3 weeks to see the full effects of lithium. This is a correct instruction.
Choice D rationale:
The client should maintain a normal sodium diet while taking lithium, not a low-sodium diet.
So, the correct answer is C, after analyzing all choices.
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