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 B
Explanation
Step 1 is B. Remain with the client and call for help. This ensures the client’s safety and gets additional assistance. Step 2 is D. Place the client in the lateral position. This prevents aspiration if the client vomits. Step 3 is C. Check the client for injuries. After the seizure has ended, the nurse should assess for any injuries that may have occurred during the seizure. Step 4 is A. Reorient and reassure the client. After a seizure, the client may be confused and scared. Reorienting and reassuring the client can help them recover. So, the correct sequence is B, D, C,
A.
Correct Answer is C
Explanation
The correct answer is: C. Avocados.
Choice A reason: Milk, especially when fresh and not aged, is generally low in tyramine. The tyramine content in milk does not significantly increase unless the milk is fermented or nearing expiration. Therefore, 2 % milk is considered a safe option for individuals taking MAOIs.
Choice B reason: Fresh fruits like apples are typically low in tyramine. However, as fruits ripen or become overripe, their tyramine content can increase. Since the question specifies “sliced apples,” which are likely to be fresh, they would not have a high tyramine content and are considered safe for someone on MAOIs.
Choice C reason: Avocados, particularly if they are overripe, contain higher levels of tyramine compared to other foods listed. Overripe avocados can have a tyramine content that is high enough to be of concern for individuals taking MAOIs, making them the food choice with the highest tyramine content among the options provided.
Choice D reason: Celery is a low-tyramine food and is safe for consumption by individuals on MAOI therapy. There is no significant increase in tyramine content in celery, even as it ages, making it a suitable option for those with dietary restrictions related to MAOIs.
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