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 B
Explanation
B. This method is recommended because the deltoid muscle is a large, rounded, triangular muscle that covers the shoulder joint.
A. This description is for locating the vastus lateralis muscle, which is commonly used for intramuscular injections in infants and young children, not adults.
C. This technique is used for locating the rectus femoris muscle, another site for intramuscular injections in infants and young children, not adults.
D. This location is too low, which could miss the muscle tissue and reduce the effectiveness of the vaccine.
Correct Answer is A
Explanation
A. A 5 mL syringe can hold up to 5 mL of fluid. It is suitable for administering 2 mL of medication, as it provides enough capacity with some additional space to ensure accurate measurement and prevent overfilling.
B. A 1 mL syringe is too small for administering a 2 mL injection. It would not accommodate the entire volume, and attempting to draw and administer 2 mL with a 1 mL syringe could result in spillage or inaccurate dosing.
C. A 10 mL syringe is larger than necessary for administering a 2 mL injection. While it can hold the required volume and more, it is bulkier and might be less convenient for administering smaller volumes like 2 mL.
D. A 3 mL syringe can also accommodate a 2 mL injection. However, a 5 mL syringe would provide a more appropriate capacity with a bit of extra space, which can be beneficial for accurate measurement and ease of administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.