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."
"My baby's fingers are looking swollen."
"There's a long red streak up my baby's arm."
"The tape is coming off the IV needle."
The Correct Answer is B
B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.
A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.
C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.
D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To calculate the rate at which the IV pump should be set to deliver the prescribed volume of intravenous fluids,
Divide the total volume of fluids (3,000 mL) by the number of hours over which they are to be administered (24 hours). This calculation gives you 125 mL/hr.
Therefore, the nurse should set the IV pump to deliver 125 mL of fluid per hour to meet the 24-hour requirement.
Correct Answer is D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
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