The nurse discovers the intravenous site is cool, edematous, and painful. What word should
the nurse use to document this finding? - ANSinfiltration
The nurse assigns a nursing assistant to care for client with a continuous intravenous
infusion. Which responsibility is appropriate to assign to the nursing assistant?
a. Changing empty IV solution containers
b. Correctly identifying that the IV is infusing as ordered
c. Assessing the clients's IV site for signs and symptoms of infection
d. Informing the nurse that client is complaining of pain at IV site - ANSd. Informing the nurse
that client is complaining of pain at IV site
The nurse is caring for a client receiving IV therapy. Which finding should be reported to the
physician?
a. Completion of each liter of fluid
b. Initiation of IV fluids
c. Infiltration
d. Extravasation - ANSd. Extravasation
is the accidental administration of intravenously (IV) infused medications into the
extravascular space/tissue around infusion sites, either by leakage (e.g., because of brittle
veins in very elderly patients), previous venipuncture (such as from blood drawn for
laboratory tests prior to therapy), or direct leakage from mispositioned venous access
devices - ANSExtravasation
s/s of Extravasation - ANSrritation, characterized by symptoms of pain and inflammation,
with the clinical signs of warmth, erythema, or tenderness.
as an inflammation of the vein, is among the most common complications of IV therapy -
ANSphlebitis
s/s of phlebitis - ANSredness, fever, pain, swelling,
The nurse is caring for a client who has experienced hypovolemia due to excessive vomiting
and diarrhea. Which type of IV fluid does the nurse anticipate will be ordered for the client? -
ANSa. Hypotonic or isotonic fluids
The nurse is caring for a client with a continuous IV infusion of Dextrose 5% in Water with 40
mEq of potassium chloride added to each liter. During a routine check, the nurse notes that 4
hours of fluid has infused in the past hour. What should be the nurse's first action?
a. Notify primary health care provider
b. Assess the client
c. Reduce the infusion rate
d. Notify the charge nurse - ANSc
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