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 D
Explanation
D. A 90° angle (perpendicular to the skin surface) is typically used for IM injections into muscles where the needle needs to penetrate deeply into the muscle tissue.
A. 60° angle is commonly used for IM injections in the deltoid muscle or thigh. However, it may not be optimal for the ventrogluteal site, which typically requires a different approach due to its deeper location and muscle structure.
B. A 45° angle is typically used for subcutaneous injections, where the needle is inserted into the fatty layer just below the skin surface.
C. This angle is steeper than 60° and is sometimes used for IM injections into muscles with thicker tissue or larger muscle mass.
Correct Answer is B
Explanation
B. It occurs when there is an abnormally high concentration of potassium in the bloodstream, typically above 5.0 mEq/L. Symptoms of hyperkalemia can include chest pain, palpitations, muscle weakness, and potentially life-threatening cardiac arrhythmias.
A. Hypercalcemia refers to elevated levels of calcium in the blood, not potassium.
C. Hypokalemia is the opposite condition where there is a lower-than-normal level of potassium in the blood.
D Hyponatremia refers to a low sodium level in the blood.
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