Which of the following symptoms most likely indicates that an infusion is infiltrated?

Correct Answer: C

Rationale: Puffiness at the site is the symptom that most likely indicates that an infusion is infiltrated. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. This can lead to swelling and puffiness at the site as the fluid accumulates in the tissue. Redness, pain, and exudate at the site are also common signs of infiltration, but puffiness specifically points towards the fluid accumulating outside the vein. If infiltration is suspected, it is important to stop the infusion, remove the IV catheter, and apply appropriate treatment based on the severity of the infiltration.

Correct Answer: C

Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.

Correct Answer: B

Rationale: Anorexia, or loss of appetite, is a common side effect of digoxin. It can lead to weight loss, weakness, and fatigue. Monitoring for anorexia is important because it may indicate digoxin toxicity, which can be serious and require intervention. Skin flushing is not a common side effect of digoxin. Hypertension is also not associated with digoxin use. Constipation is generally not a common side effect of digoxin. Therefore, anorexia is the assessment that indicates a potential side effect of digoxin that requires follow-up.

Correct Answer: D

Rationale: Autoimmunity is a phenomenon in which the immune system mistakenly targets and attacks the body's own cells, tissues, and organs. This occurs due to a breakdown in the immune system's ability to differentiate "self" from "nonself." In a healthy immune system, immune cells recognize and destroy foreign invaders while avoiding attacking the body's own cells. When this self-tolerance is lost, autoimmune diseases can develop, leading to inflammation, tissue damage, and various health problems. Therefore, autoimmunity is defined by the immune system's inability to distinguish between self and nonself.

Correct Answer: E

Rationale: Clients with immune system disorders may receive treatments such as immunoglobulin therapy or biologic agents through infusions. It is essential for the nurse to monitor the client for infusion reactions, which can include symptoms such as fever, chills, nausea, and allergic reactions. Early recognition of infusion reactions is crucial for prompt intervention to prevent complications and ensure the client's safety. By closely monitoring the client during and after the infusion, the nurse can detect and address any adverse reactions promptly.