you are making initial shift assessments on your patients while assessing one patients peripheral iv site you note edema around the insertion site ho
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

Correct answer: C

Rationale:

2. Place a washcloth between the skin and tourniquet

Correct answer: D

Rationale:

3. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.

4. The nurse assessing skin turgor in an elderly patient should remember that:

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

5. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?

Correct answer: A

Rationale:

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