Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Reddish streak proximal to the insertion site

Skin is pale and taut

The vein is firm and cord-like

IV fluid leaking from insertion site

Warmth at the insertion site

Answer and Explanation

Correct Answer : B,D,E

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.

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Correct Answer is D

Explanation

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

A. Ask why the client is taking steroid therapy B. Notify the surgeon immediately C. Administer an IV equivalent dose of Prednisone D. Give the oral steroid with a small sip of water

Correct Answer is C

Explanation

A. Ask why the client is taking steroid therapy: While understanding the reason for steroid therapy is important, it does not address the immediate need to manage the medication administration.
B. Notify the surgeon immediately: Notifying the surgeon might be necessary if there are specific concerns, but it is not the most immediate action regarding medication administration.
C. Administer an IV equivalent dose of Prednisone: Since the client is NPO, administering an oral medication could be contraindicated. Administering an IV equivalent ensures the client receives the necessary steroid therapy without risking complications from taking oral medication while fasting.
D. Give the oral steroid with a small sip of water: This may not be appropriate due to the NPO status, which typically restricts oral intake.

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Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

Correct Answer is D

Explanation

A client is scheduled for surgery at 0800 and has been NPO (nothing by mouth) since midnight. They have been taking long-term oral steroids and are scheduled for their routine dose of Prednisone 30 mg PO to be administered at 0600. Which nursing action is most appropriate?

Correct Answer is C

Explanation

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