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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Replace the ear molds once per year" is incorrect. Ear molds should be checked regularly for wear and tear, but they should be replaced as needed rather than on a fixed schedule like once a year.
B. "Clean the hearing aid with a soft cloth" is correct. Cleaning the hearing aid with a soft cloth helps to maintain the device, removing dirt and debris without damaging the electronics. It is important to avoid using harsh chemicals or abrasive materials that could harm the hearing aid.
C. "Disinfect the hearing aid with isopropyl alcohol" is incorrect. Isopropyl alcohol is too harsh for cleaning hearing aids and can damage the components. The hearing aid should only be cleaned with appropriate methods, such as a dry cloth or cleaning brush.
D. "Change the battery once per month" is incorrect. The battery should be checked more frequently, as it typically needs to be replaced more often (e.g., every 7-10 days), depending on usage. Changing it once a month may not ensure optimal performance.
Correct Answer is B
Explanation
A. To stay with the client's body for 8 hr following their death: While it is common for family members to stay with the deceased, the duration of time can vary and is not specifically aligned with Hindu customs.
B. To cremate the client's body: In Hinduism, cremation is the most common practice following death. The family is likely to request this as it aligns with religious beliefs and traditions.
C. To prohibit medical personnel from touching the client's body: In Hinduism, there is no blanket prohibition against medical personnel touching the body. However, some families may have specific requests for the handling of the body, but this is not universally expected.
D. To bury the client's body within 24 hr of their death: Hindus typically prefer cremation rather than burial. While burial is practiced in certain Hindu traditions, cremation is far more common, and the request for burial within 24 hours may not apply.
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