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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypotension: Gentamicin is an aminoglycoside antibiotic that primarily affects the kidneys and auditory system rather than blood pressure. Hypotension is not a common adverse effect of gentamicin; however, dehydration related to nephrotoxicity could contribute to blood pressure fluctuations.
B. Hearing loss: Ototoxicity is a known adverse effect of gentamicin due to its accumulation in the inner ear, leading to damage of the cochlear and vestibular structures. Clients may report tinnitus, dizziness, or difficulty hearing, and prolonged exposure increases the risk of irreversible auditory impairment.
C. Hyperthermia: Fever is typically a sign of infection rather than an adverse effect of gentamicin. While aminoglycosides can cause fever in rare cases due to a drug-induced reaction, hyperthermia is not a common side effect and should prompt evaluation for worsening infection or another underlying cause.
D. Constipation: Gentamicin does not significantly affect gastrointestinal motility. While some antibiotics may cause gastrointestinal upset, nausea, or diarrhea, constipation is not a recognized adverse effect of gentamicin therapy.
Correct Answer is A
Explanation
A. Inject 15 units of air into the regular insulin vial. When mixing NPH and regular insulin, air is first injected into both vials without touching the solution. After injecting air into the NPH vial, the next step is to inject air into the regular insulin vial to maintain proper vial pressure before withdrawing the dose.
B. Place the cap over the needle. Recapping needles increases the risk of needlestick injuries and is not necessary during the insulin preparation process. The needle should remain uncapped until both insulins are drawn and the injection is ready.
C. Withdraw 10 units of NPH insulin. Regular insulin should be drawn first to prevent contamination with NPH insulin. Since NPH is a cloudy suspension and regular insulin is clear, drawing regular insulin first ensures that the short-acting insulin remains unaltered.
D. Verify the dosage with another nurse. While verifying high-risk medications like insulin is important, the appropriate step after injecting air into the NPH vial is to proceed with injecting air into the regular insulin vial before withdrawing any insulin.
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