A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

The client's left arm is cool to the touch.

The client's left arm is swollen.

There is a red streak up the client's left arm.

The client reports tenderness at the IV insertion site.

The client reports cramping above the insertion site.

Answer and Explanation

Correct Answer : A,B

A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.

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Correct Answer is D

Explanation

A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.

A. Empty the collection chamber every 8 hr. B. Place the client in a supine position. C. Ensure the device is kept below the level of the client's chest. D. Clamp the chest tube every 4 hr.

Correct Answer is C

Explanation

A. "Empty the collection chamber every 8 hr." The collection chamber should not be emptied on a regular schedule like every 8 hours. It should be emptied when it becomes full or according to facility policy. Regular monitoring of the chamber is essential to assess drainage and ensure it does not exceed capacity.
B. "Place the client in a supine position." The client should not be placed in a supine position when a chest tube is in place for a pneumothorax. The optimal position is typically sitting up or at least semi-Fowler’s position to facilitate lung expansion and drainage.
C. "Ensure the device is kept below the level of the client's chest." Keeping the chest tube drainage system below the level of the client’s chest is crucial for proper drainage and to prevent backflow of fluid or air. This position facilitates gravity drainage and helps maintain the effectiveness of the suction.
D. "Clamp the chest tube every 4 hr." Clamping the chest tube is generally not recommended unless specifically ordered by a healthcare provider. Clamping can lead to increased pressure in the pleural space and risk of tension pneumothorax. The nurse should avoid clamping unless there is a clear and appropriate reason to do so.

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A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

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