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NurseDive Free Nursing Practice Question
A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?
A. Apply pressure to the IV site.
Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection. Pressure can also obstruct blood flow and cause thrombophlebitis.
B. Elevate the extremity.
This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.
C. Slow the infusion rate.
Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues. Slowing the infusion rate can also delay the delivery of medication or fluid to the client.
D. Flush the IV catheter.
Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues. Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications. Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.
Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.
Pressure can also obstruct blood flow and cause thrombophlebitis.
Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.
Slowing the infusion rate can also delay the delivery of medication or fluid to the client.
Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.
Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.
Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.
Similar Questions
A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 Ib) since the last visit 2 days ago.
Which of the following actions should the nurse take first?
A. Teach the client about foods low in sodium.
Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take. While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.
B. Determine medication adherence by the client.
Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take. While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.
C. Encourage the client to dangle the legs while sitting in a chair.
Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take. While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.
D. Notify the provider of the client’s weight gain.
This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.
Full Explanation
This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.
The provider should be informed of this change as soon as possible to prevent further complications.
Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.
While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.
Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.
While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.
Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.
While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.
A nurse is planning to administer medications to an older adult client who has dysphagia.
Which of the following actions should the nurse plan to take?
A. Mix the medications with a semisolid food for the client.
Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.
B. Administer more than one pill to the client at a time.
Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.
C. Place the medications on the back of the client’s tongue.
Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.
D. Tilt the client’s head back when administering the medications.
ilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.
Full Explanation
The nurse should plan to take the following action:
A) Mix the medications with a semisolid food for the client.
Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.
Options B, C, and D are not recommended for a client with dysphagia:
B) Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.
C) Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.
D) Tilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.
A nurse is preparing to initiate IV therapy for a client.
Which of the following sites should the nurse use to place the peripheral IV catheter?
A. Dominant antecubital basilic vein.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
B. Nondominant dorsal venous arch.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
C. Dominant distal dorsal vein.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
D. Nondominant forearm basilic vein
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
Full Explanation
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.