Practice Question
A nurse is attending to 72-year old non-compliant diabetic patient receiving a continuous IVF infusion. The patient complains of a burning sensation at the now edematic cannulation site with noticeable erythema. Considering the symptoms reported, what is the most obvious conclusion?
Answer Choices:
Correct Answer:
Infiltration
Rationale:
🟠Infiltration occurs when IV fluid leaks into the surrounding tissue due to dislodged or damaged cannula.
🟠Early signs include edema, erythema, and burning or discomfort at the insertion site, as seen in this client.
🟠The affected area may feel cool or firm and show slowed infusion rate.
🟠Immediate nursing actions include stopping the infusion, removing the catheter, elevating the limb, and applying a warm compress.
🟠Timely recognition prevents tissue injury and compromised circulation.
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This question is from Custom Fundamentals unit Exam 2 Fall 2025 which contains 65 questions.
More Questions from This Exam
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non- modifiable risk factor for disease?
Answer Choices:
A. Genetics
B. Smoking
C. Unhealthy diet
D. Sunbathing
Which of the following is a primary goal of medication reconciliation?
Answer Choices:
A. To determine the cost-effectiveness of the prescribed medications.
B. To identify and resolve discrepancies in the patient's medication list.
C. To prepare a list of medications for insurance billing purposes.
D. To ensure the patient has enough medication for the duration of their treatment.
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
Answer Choices:
A. Bradypnea.
B. Hypertension.
C. Peripheral edema.
D. Cyanosis.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
Answer Choices:
A. Retractions.
B. Restlessness.
C. Diaphoresis.
D. Cyanosis.
When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?
Answer Choices:
A. Initiate bedrest in semi-Fowler's position.
B. Instruct the client to limit fluid intake to less than 2,000 mL/day.
C. Repeat the auscultation after asking the client to breathe deeply and cough.
D. Prepare to administer antibiotics.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4