The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

flush the catheter with normal saline prior to and after medications.

secure the IV catheter to the extremity.

assess IV site frequently throughout the shift.

prevent contamination during the catheter insertion.

Answer and Explanation

The Correct Answer is C

C. Regular assessment of the IV site is crucial to detect early signs of infiltration. Signs of infiltration include swelling, coolness, pain, or blanching around the insertion site. Assessing the site allows nurses to intervene promptly if infiltration occurs, preventing further complications such as tissue damage or fluid overload.

A. Flushing the IV catheter with normal saline helps to maintain patency and prevent blockage of the catheter. It also ensures that medications are effectively delivered into the bloodstream. While this action is important for maintaining the function of the IV catheter, it primarily addresses patency rather than preventing infiltration directly.

B. Securing the IV catheter to the extremity with a securement device (such as tape or a transparent dressing) helps prevent accidental dislodgement or movement of the catheter. This reduces the risk of

mechanical irritation at the insertion site, which can contribute to infiltration. Proper securement also ensures that the catheter remains in place during movement or patient activities.

D. Proper technique during catheter insertion helps reduce the risk of infection and subsequent complications, but it also indirectly contributes to preventing infiltration. Contamination during insertion can lead to inflammation or infection at the site, which may increase the risk of infiltration due to compromised tissue integrity.

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Correct Answer is B

Explanation

B.This formulation is not intended for administration through a gastrostomy tube and could be harmful to the patient. It is essential to consult with a pharmacist or physician to find a suitable alternative that is safe for administration through the gastrostomy tube

A. Ibuprofen is typically administered orally (PO) and is absorbed in the gastrointestinal tract.

C. Levothyroxine is a thyroid hormone replacement medication crucial for maintaining thyroid hormone levels in individuals with hypothyroidism. It is typically administered orally in the morning on an empty stomach to ensure optimal absorption.

D. Liquid formulations are suitable for administration through gastrostomy tubes, as they are generally well-tolerated and absorbed.

A. Administering oxygen during provision of care B. Assessing response to activity C. Providing rest periods every ten minutes D. Maintaining the bed in high-Fowler's position

Correct Answer is B

Explanation

B. Before, during, and after providing hygiene care, the nurse should continually assess the client's response to activity. Signs such as increased heart rate, shortness of breath, fatigue, or discomfort should be monitored closely. Assessing the client's response allows the nurse to adjust care activities as needed to prevent exacerbation of symptoms or complications.

A. Administering oxygen may be necessary if the client has respiratory compromise or if oxygen saturation levels are low during activities. However, this intervention should be based on the client's specific needs as assessed by the nurse and should not necessarily be a routine intervention

C Providing regular rest periods is an important intervention for clients with activity intolerance. However, the assessment will guide how and when these interventions should be implemented.

D. Fowler's position are also important, but the assessment will guide how and when these interventions should be implemented.

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The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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