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. 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.

A. Pulmonary embolism B. Pneumonia C. Hemorrhage D. Myocardial infarction

Correct Answer is A

Explanation

A. Pulmonary embolism: Pulmonary embolism presents with sudden onset of chest pain, tachycardia, hypotension, and restlessness, which aligns with the client's symptoms. It is a common postoperative complication due to immobility and potential hypercoagulability.
B. Pneumonia: Pneumonia typically develops more gradually and presents with fever, productive cough, and respiratory distress rather than sudden chest pain and hemodynamic instability. It is less likely in the immediate postoperative period.
C. Hemorrhage: Hemorrhage would also cause tachycardia and hypotension, but it would typically present with symptoms such as excessive bleeding, swelling at the surgical site, and pallor rather than chest pain.
D. Myocardial infarction: While myocardial infarction can cause chest pain, tachycardia, and hypotension, it is less likely in this scenario compared to a pulmonary embolism, given the timing and nature of the symptoms in the immediate postoperative period.

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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

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