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. pH 7.25, PaCO2 61, HCO3 26

pH is decreased (acidosis).

PaCO2 is elevated (61 mmHg), indicating respiratory acidosis (increased CO2 retention). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.

A. pH 7.45, PaCO2 35, HCO3 22

pH is within normal range (7.35-7.45).

PaCO2 is slightly lower than normal (35 mmHg), indicating mild respiratory alkalosis. HCO3 (bicarbonate) is within normal range (22 mEq/L).

C. pH 7.23, PaCO2 27, HCO3 25

pH is decreased (acidosis).

PaCO2 is lower than normal (27 mmHg), indicating respiratory alkalosis (which is unlikely in the context of morphine overdose with hypoventilation).

HCO3 is within normal range (25 mEq/L).

D. pH 7.54, PaCO2 59, HCO3 26

pH is increased (alkalosis).

PaCO2 is elevated (59 mmHg), indicating respiratory acidosis (consistent with hypoventilation). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.

A. Previous experiences B. Culture C. Socioeconomic status D. Emotions E. Age

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Previous experiences with pain can significantly influence how individuals perceive and respond to pain in the future. Positive experiences may lead to better coping strategies, while negative experiences could increase fear and anxiety associated with pain.

B. Cultural beliefs, norms, and practices surrounding pain vary widely across different societies. Culture shapes how individuals express pain, interpret pain severity, and seek treatment. For instance, some cultures may encourage stoicism in the face of pain, while others may emphasize the importance of verbalizing discomfort.

C. Socioeconomic status can impact access to healthcare resources, including pain management options. Higher SES individuals may have better access to healthcare facilities, medications, and therapies, whereas lower SES individuals may face barriers to adequate pain relief due to financial constraints or limited healthcare services.

D. Emotional states such as anxiety, depression, stress, and fear can significantly influence the perception and experience of pain. These emotions can amplify pain perception and interfere with pain management strategies. Conversely, positive emotions and a sense of well-being may help reduce the intensity of pain.

E. Age-related factors can affect how pain is perceived and managed. Children and older adults, for example, may experience pain differently due to developmental stages, cognitive abilities, and physiological changes. Pain assessment and management approaches need to be tailored accordingly to address age-specific considerations.

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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 ["A","B","C","D","E"]

Explanation

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