During a clinical rotation on an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool, blanched and slightly swollen. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?

Infiltration

Local inflammation

Thrombophlebitis

Phlebitis

Answer and Explanation

The Correct Answer is A

A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.

B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.

C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.

D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.

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Correct Answer is B

Explanation

B. Dextrose 10% in water is a solution that contains a high concentration of glucose (dextrose). Infusing D10W can lead to an increase in blood glucose levels, especially if the client's body cannot metabolize the glucose effectively (e.g., in diabetic patients or those with impaired glucose tolerance).

A. Dextrose 10% in water does not contain calcium. Hypercalcemia refers to elevated calcium levels in the blood, which can occur due to various causes such as hyperparathyroidism or excessive vitamin D intake, but not from D10W infusion.

C. Dextrose 10% in water is not used to treat hypovolemia (low blood volume). It is a solution primarily used to provide calories and prevent ketosis rather than to expand circulating blood volume.

D. Dextrose 10% in water does not contain potassium. Hypokalemia (low potassium levels) can occur due to various reasons such as diuretic use, gastrointestinal losses, or inadequate intake, but it is not directly related to D10W infusion.

A. "Daily bowel movements are necessary for good intestinal health." B. "Decrease your intake of high-fiber foods." C. "Chronic use of laxatives can lead to a tear in the rectal mucosa." D. "Excessive laxative use can cause rectal burning, dehydration and electrolyte imbalance."

Correct Answer is D

Explanation

D Excessive use of bisacodyl or other laxatives can indeed cause these adverse effects. Rectal burning can occur due to irritation from frequent bowel movements, while dehydration and electrolyte imbalance can result from fluid loss caused by frequent laxative use.

A. While regular bowel movements are important for many individuals, daily bowel movements are not necessary for everyone and can vary depending on diet, hydration, and individual health conditions.

B. Bisacodyl is a stimulant laxative used for short-term relief of constipation. It does not interact with dietary fiber intake, nor should the client necessarily decrease high-fiber foods unless specifically advised by their healthcare provider for other reasons.

C. Chronic use of bisacodyl, a stimulant laxative, can indeed lead to dependence and potentially harmful effects on the body's water and salt balance

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who reports taking bisacodyl daily. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

A nurse is collecting data from an older adult client who is receiving ondansetron IV, has a history of diabetes mellitus and cardiac myopathy, and is receiving chemotherapy to treat cancer. For which of the following adverse effects of ondansetron should the nurse monitor? (Select all that apply)

A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?

A nurse is reinforcing teaching with a client who has a prescription for amoxicillin 5 mL PO. How many teaspoons (tsp) should the nurse instruct the client to take?

Before administering intravenous (IV) amoxicillin, the nurse should do what?

For a patient who is experiencing an ECV excess, the nurse plans to determine the fluid status. The best way for the nurse to determine the fluid balance for the patient is to: