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
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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Related Questions
Correct Answer is D
Explanation
A. Administer 10% sodium chloride via rapid infusion: Rapid infusion of high concentrations of sodium chloride can be dangerous and is not the standard treatment for severe hyponatremia.
B. Administer intranasal antidiuretic hormone: This would not be appropriate for correcting severe hyponatremia and could potentially worsen the condition.
C. Encourage oral fluid intake: For severe hyponatremia, oral fluid intake might not be sufficient and could exacerbate the condition if there is fluid overload.
D. Place the client on seizure precautions: This is the correct choice. Severe hyponatremia (sodium < 120 mEq/L) can lead to neurological symptoms and seizures, so implementing seizure precautions is crucial for safety.
Correct Answer is D
Explanation
A. Dry oral mucus membranes: This finding indicates dehydration rather than improvement. Effective treatment would result in the rehydration of mucous membranes.
B. Weight loss: Weight loss can be a sign of ongoing dehydration or fluid loss. Effective treatment would be indicated by weight stabilization or gain, not loss.
C. Jugular vein distention: Jugular vein distention typically indicates fluid overload or poor cardiac function, not improvement in dehydration. Effective rehydration would be associated with a return to normal vein appearance.
D. Daily urine output of 960 mL: This is the correct choice as it reflects adequate fluid intake and kidney function. For an average adult, a daily urine output of around 960 mL suggests proper hydration, indicating that interventions have been effective.
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