The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:
every 5 hours
once per shift
hourly
once a day
The Correct Answer is C
C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.
A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.
B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.
D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
Correct Answer is B
Explanation
B. It occurs when there is an abnormally high concentration of potassium in the bloodstream, typically above 5.0 mEq/L. Symptoms of hyperkalemia can include chest pain, palpitations, muscle weakness, and potentially life-threatening cardiac arrhythmias.
A. Hypercalcemia refers to elevated levels of calcium in the blood, not potassium.
C. Hypokalemia is the opposite condition where there is a lower-than-normal level of potassium in the blood.
D Hyponatremia refers to a low sodium level in the blood.
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