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. New onset of hearing loss. Gentamicin is an aminoglycoside antibiotic known for its ototoxic effects, which can lead to irreversible hearing loss or vestibular dysfunction. The drug damages the hair cells in the inner ear, resulting in symptoms like tinnitus, dizziness, or difficulty hearing. Clients receiving gentamicin should be closely monitored for auditory changes, as early detection can help prevent worsening damage.
B. Constipation. Gentamicin does not typically affect gastrointestinal motility, making constipation an unlikely adverse effect. It primarily causes nephrotoxicity and ototoxicity, with its main targets being the kidneys and inner ear. Gastrointestinal side effects are rare and usually limited to nausea or mild discomfort rather than significant bowel irregularities.
C. Slurred speech. While aminoglycosides can cause neuromuscular blockade in rare cases, slurred speech is not a common adverse effect. More frequently, gentamicin affects the vestibular system, leading to balance disturbances or dizziness rather than impairing speech function. If neuromuscular symptoms develop, the medication should be reassessed to prevent severe complications.
D. Hypotension. Gentamicin does not directly cause hypotension as a primary side effect. Its adverse effects are more commonly associated with kidney damage, ototoxicity, and, in rare cases, neuromuscular paralysis. If a client on gentamicin experiences hypotension, other underlying causes such as sepsis or volume depletion should be considered.

A. Report of weight change B. Client heart rate C. Deep tendon reflexes D. Fetal heart rate E. Pain rating F. Oxygen saturation level G. Report of vaginal discharge

Correct Answer is ["B","D","E","G"]

Explanation

A. Report of weight change. A slight weight loss near term is a common finding as the body prepares for labor. This is not an immediate concern.
B. Client heart rate. The heart rate increased from 90/min at 0830 to 110/min at 0845. A rising maternal heart rate could indicate dehydration, pain, or early signs of infection.
C. Deep tendon reflexes. Reflexes are documented as 2+, which is within the expected range and does not indicate hyperreflexia or hyporeflexia.
D. Fetal heart rate. The FHR at 1530 is 120/min with late decelerations, which is concerning. Late decelerations suggest uteroplacental insufficiency, requiring further assessment and possible interventions such as maternal repositioning, oxygen administration, or fluid bolus.
E. Pain rating. The client reports severe back pain rated as 10/10, which may indicate fetal malposition (such as occiput posterior positioning) or rapid labor progression, both requiring evaluation and possible intervention.
F. Oxygen saturation level. The oxygen saturation has remained stable between 96% and 97%, which is within the expected range and does not require immediate intervention.
G. Report of vaginal discharge. An increased amount of blood-tinged discharge at 1530 may indicate cervical dilation or potential complications such as placental abruption, especially in the presence of late decelerations.

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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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