A client receiving chemotherapy through an IV complains of pain, burning, and swelling around the IV site. The nurse notices the skin turning red and blistering. Which complication of IV therapy should the nurse suspect?
Phlebitis
Infiltration
Fluid overload
Extravasation
The Correct Answer is D
A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.
B) This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.
C) This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.
D) This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not coolness and pallor.
B) This choice is correct. The client's symptoms of swelling, coolness, and pallor around the insertion site, along with a slowed infusion and discomfort, are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.
C) This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.
D) This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as swelling and coolness around the IV site.
Correct Answer is D
Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, tachycardia, and hypotension.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, tachycardia, and hypotension.
C) This choice is incorrect because fluid overload is not associated with symptoms of fever, tachycardia, and hypotension. It is characterized by symptoms such as dyspnea and edema.
D) This choice is correct. The client's symptoms of fever, tachycardia, and hypotension are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.
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