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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

A. Laissez-faire leadership style B. Rigid expectations of behavior C. Self-blame for financial problems D. High self-esteem

Correct Answer is B

Explanation

A. Laissez-faire leadership style: A laissez-faire leadership style generally involves being permissive or non-directive, which is not typically associated with perpetrators of child abuse. Instead, abusive caregivers often have controlling or rigid parenting styles.

B. Rigid expectations of behavior: This is characteristic of many perpetrators of child abuse. They may have unrealistic or excessively strict expectations for their children's behavior, which can lead to frustration, anger, and, ultimately, abusive behaviors when those expectations are not met.

C. Self-blame for financial problems: While perpetrators of child abuse may experience stress due to financial issues, self-blame is not a defining characteristic. The stress from financial problems can contribute to abusive behaviors, but it is not the key factor.

D. High self-esteem: Perpetrators of child abuse typically have low self-esteem and may feel inadequate as parents. High self-esteem is not generally a characteristic of individuals who abuse children. Instead, feelings of powerlessness or frustration often contribute to abusive behavior.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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