A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?
Erythema
Edema
Blood
Pruritus
The Correct Answer is B
A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.
B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.
C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.
D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "My partner and I will use petroleum jelly with latex condoms.": Petroleum jelly should not be used with latex condoms as it can weaken the latex material, increasing the risk of condom breakage. Water-based lubricants are recommended with latex condoms.
B. "My partner and I will both use a condom during intercourse.": This is not necessary or recommended. Only one condom is needed, and using two (male and female condom) may cause friction and increase the likelihood of breakage.
C. "I will be able to remove my contraceptive sponge immediately after intercourse.": The sponge should be left in place for at least 6 hours after intercourse to allow its spermicide to be effective. Removing it immediately could reduce the effectiveness of the contraceptive.
D. "My partner will use condoms with spermicides, which works better.": This statement demonstrates understanding. Using condoms with spermicides can be an effective form of contraception, as the spermicide helps to kill or immobilize sperm, providing an additional layer of protection.
Correct Answer is D
Explanation
A. The medication (erythromycin) is clearly identified in the prescription, so no clarification is needed regarding the drug name itself. B. The dosage (500 mg) is specified in the order, which is a standard dose for this medication, so it does not require clarification. C. The time or frequency is provided as “four times per day.” While specific facility times may need to be assigned, the frequency of administration is clearly established in the order. D. The route is entirely missing from the prescription. Erythromycin can be administered via several different routes, such as orally or intravenously, and the nurse cannot assume the intended method. This is a critical omission that must be clarified for safe transcription.
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