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. Sit on the client's right side. This is not the best approach. If the client has hearing loss in one ear, the nurse should sit on the side of the client’s better ear, not necessarily the right side.
B. Choose a room that is well-lit and free from background noise. This is the correct choice. A well-lit room helps the client read lips or better perceive any non-verbal cues. Reducing background noise ensures the client can focus on hearing or understanding speech without distractions.
C. Exaggerate lip movement while speaking. While some individuals with hearing loss may rely on lip-reading, exaggerating lip movement can make it more difficult to understand. It is more effective to speak clearly without overemphasizing movements.
D. Ask a few questions at a time. This is not the best strategy. It is better to ask one clear, simple question at a time to ensure the client understands, as too many questions at once can overwhelm them.
Correct Answer is B
Explanation
A. This medication will increase the immunity of your newborn.: Vitamin K does not directly affect the immunity of a newborn. It plays a crucial role in blood clotting, not immune function.
B. This medication will decrease the risk of hemorrhage in your newborn.: Vitamin K is given to newborns to prevent bleeding or hemorrhagic disease, as newborns have low levels of vitamin K at birth, which is essential for clotting.
C. This medication will decrease the possibility of your newborn developing jaundice.: Vitamin K does not have a role in preventing jaundice, which is related to elevated bilirubin levels in the blood.
D. This medication will increase the absorption of nutrients in the intestines.: Vitamin K does not influence nutrient absorption in the intestines; it primarily supports blood clotting by helping in the synthesis of clotting factors.
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