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 A
Explanation
A. Pantoprazole belongs to a class of medications called proton pump inhibitors (PPIs), which work by reducing the production of gastric acid in the stomach. This helps in treating conditions such as gastroesophageal reflux disease (GERD) and heartburn effectively.
B. Pantoprazole is not known to cause hyperkalemia. Hyperkalemia is a condition characterized by high levels of potassium in the blood, and it is typically associated with certain medications (e.g., potassium- sparing diuretics) or medical conditions affecting kidney function. Pantoprazole's primary side effects relate to its effects on gastric acid production and absorption of certain nutrients.
C. While pantoprazole is usually taken once daily, the timing of administration is typically in the morning, before a meal. This helps to maximize its effectiveness in reducing gastric acid secretion when the stomach acid production is at its highest.
D. Pantoprazole should be taken on an empty stomach, at least 30 minutes before a meal. This timing allows the medication to be absorbed properly and work effectively to reduce gastric acid production.
Correct Answer is C
Explanation
C. This method is recommended because it is less painful, as the sides of the fingertips have fewer nerve endings compared to the pads or 'balls' of the fingers.
A. Avoiding the use of the thumbs is not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
B. Avoiding the use of the dominant hand's fingers are not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
D. Using the ball of the finger is not recommended for blood glucose monitoring because it can be more painful and may lead to less blood flow, resulting in difficulty obtaining an adequate blood sample.
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