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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. This range represents the normal serum magnesium level. It is important for maintaining neuromuscular function and other vital processes in the body.

A. This range is too low for normal serum magnesium levels. Magnesium levels below this range can indicate hypomagnesemia, which can lead to symptoms such as muscle cramps, tremors, and cardiac arrhythmias.

C. This range is too high for normal serum magnesium levels. Elevated magnesium levels (hypermagnesemia) can occur in conditions such as renal failure or excessive magnesium intake, leading to symptoms like weakness, decreased reflexes, and in severe cases, cardiac arrest.

D. While this range is broader and includes the correct normal range (1.3-2.1 mEq/L), it also includes values that are below and above normal. Values below 1.3 mEq/L can indicate hypomagnesemia, while values above 2.1 mEq/L can indicate hypermagnesemia.

A. obtain diagnostic test results B. weigh the patient daily C. monitor IV fluid intake D. assess vital signs

Correct Answer is B

Explanation

B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.

A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.

C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.

D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.

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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?

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