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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
A chest x-ray is an essential diagnostic tool for evaluating a client with symptoms such as a productive cough, blood-tinged sputum, weight loss, night sweats, and a low-grade fever. These findings raise suspicion for tuberculosis (TB), particularly given the client’s recent travel to South Africa, where TB is more prevalent. A chest x-ray can help identify characteristic abnormalities such as upper lobe infiltrates, cavitations, or pleural effusions that are consistent with pulmonary TB.
A nasopharyngeal swab is primarily used to detect viral respiratory infections, such as influenza or COVID-19. While the client presents with a cough and fever, the chronic nature of symptoms and presence of hemoptysis make a viral infection less likely. Furthermore, viral infections typically present with acute onset symptoms rather than a prolonged illness with weight loss and night sweats.
Blood cultures are used to identify systemic bacterial infections, such as bacteremia or sepsis. Although the client has a fever, there are no indications of severe systemic infection, such as hypotension or signs of shock, making blood cultures a lower priority in this case.
A pulmonary function test evaluates lung function in conditions such as asthma or chronic obstructive pulmonary disease (COPD). The client has no history of these conditions, and their primary complaint involves symptoms suggestive of an infectious process rather than an obstructive pulmonary disease. Pulmonary function testing is not indicated for diagnosing TB or other respiratory infections.
A Mantoux test (tuberculin skin test) is a key diagnostic tool in assessing tuberculosis exposure. Given the client’s symptoms and travel history, this test helps determine prior exposure to Mycobacterium tuberculosis and the likelihood of latent or active infection. A positive test would support further diagnostic testing, such as sputum cultures, to confirm active TB disease.
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