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Author Question: A nurse enters a client's room to check on his intravenous infusion. An electronic infusion device ... (Read 43 times)

LaDunn

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A nurse enters a client's room to check on his intravenous infusion. An electronic infusion device is not being used.
 
  When checking the solution container and rate, the nurse notes that that fluid is infusing at a rate slower than intended. When assessing the client, which finding would the nurse identify as most likely contributing to the slowed rate of infusion?
  A) The client is resting his arm with the IV on his head.
  B) The tubing is visible, running freely from the solution to the access site.
  C) The fluid, although running slow, is infusing.
  D) The client is using his non-IV hand to push the IV pole when ambulating.

Question 2

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply.
 
  A) Swelling
  B) Redness
  C) Pallor
  D) Warmth to touch
  E) Pain



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jaymee143

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Answer to Question 1

Ans: A
Feedback:
When the extremity is elevated, such as the client resting his arm on his head, the fluid will infuse more slowly. Kinked or obstructed tubing (not visible and running freely), a patent catheter (such that the fluid is infusing), and the height of the solution container (such as when the client gets up and walks in the hall pushing the IV pole with the hand containing the IV) are factors that would contribute to a slowed rate.

Answer to Question 2

Ans: A, C, E
Feedback:
Infiltration is manifested by pain and by swelling around the infusion site which usually becomes cool to the touch. The area is also pale in color. Warmth and redness suggest phlebitis.





 

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