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 B

Explanation

A. Believes that his brother's death will be reversible. This response is more typical of preschool-aged children (ages 3 to 5), who often perceive death as temporary or reversible, similar to sleep or separation. School-age children, however, begin to understand the finality of death, though they may still struggle with its implications.
B. Believes his bad behavior is causing his brother's death. School-age children (ages 6 to 12) often engage in magical thinking and may believe that their actions, thoughts, or behaviors are responsible for events, including illness and death. They may feel guilt and self-blame, thinking that past misbehavior contributed to their sibling's condition. Providing reassurance and education about the medical causes of the illness can help alleviate these feelings.
C. Alienates himself from his peers. While social withdrawal can occur in grieving children, school-age children typically seek peer support and may use friendships as a coping mechanism. Alienation is more commonly seen in adolescents, who might isolate themselves due to difficulty expressing emotions or fear of burdening others.
D. Regresses to an earlier developmental level. Regression, such as bedwetting, clinging behavior, or baby talk, is more commonly seen in younger children, particularly toddlers and preschoolers, when they experience stress or grief. School-age children are more likely to express distress through guilt, sadness, or behavioral changes rather than regression.

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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