a nurse is caring for a client who reports burning around the peripheral iv site what finding should the nurse identify as a manifestation of infiltra a nurse is caring for a client who reports burning around the peripheral iv site what finding should the nurse identify as a manifestation of infiltra
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Nursing Elites

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ATI Capstone Fundamentals Assessment Proctored

1. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?

Correct answer: B

Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.

2. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably indicate that the patient is experiencing:

Correct answer: A

Rationale: The symptoms of fatigue, muscle cramping, and muscle weakness in a patient after starting furosemide therapy are indicative of hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion, causing hypokalemia. Hypokalemia can manifest with muscle weakness, cramps, and fatigue due to alterations in neuromuscular function and decreased ATP production.

3. A client with preterm labor is being admitted. The nurse anticipates a prescription by the provider for which of the following medications?

Correct answer: Indomethacin

Rationale: Indomethacin is used to delay premature labor by inhibiting uterine contractions. Prostaglandin E2, Methylergonovine, and Oxytocin are not typically used to manage preterm labor. Prostaglandin E2 can be used for cervical ripening and labor induction. Methylergonovine is used to prevent or control postpartum hemorrhage. Oxytocin is used for labor induction and augmentation of labor in term pregnancies.

4. A nurse is caring for a client who is lactose intolerant. Which of the following clinical manifestations should the nurse assess be?

Correct answer: C

Rationale: Cramping is a common clinical manifestation of lactose intolerance due to the inability to digest lactose properly.

5. During operation, who manages the lighting, noise, temperature and other factors in the operating room suite?

Correct answer: C: Circulating Nurse

Rationale: In an operating room, the circulating nurse is responsible for managing environmental factors such as lighting, noise, and temperature. This role includes ensuring the comfort and safety of the patient, as well as the efficiency of the team. While the Nurse Supervisor, Surgeon, and Scrub Nurse also have crucial roles during an operation, they do not directly manage the environmental conditions of the operating room. The rationale provided does not directly address the question asked, and appears to relate more to the broader role of nursing in patient care.

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