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 C
Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with purulent drainage and redness.
B) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, but it does not cause purulent drainage.
C) This choice is correct. The client's symptoms of tenderness, redness, warmth, and purulent drainage around the insertion site are indicative of an infection, which can occur as a complication of IV therapy if bacteria enter the bloodstream through the catheter.
D) This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.
Correct Answer is D
Explanation
A) This choice is incorrect because phlebitis and infiltration typically do not cause chest pain, dyspnea, and tachycardia.
B) This choice is incorrect because infiltration is associated with localized symptoms around the IV site, not systemic symptoms like chest pain and dyspnea.
C) This choice is incorrect because fluid overload may cause respiratory distress and tachycardia, but it is not typically associated with sudden chest pain.
D) This choice is correct. The client's symptoms of sudden chest pain, dyspnea, and tachycardia are potential signs of an air embolism, which occurs when air enters the vascular system through the IV catheter and can lead to serious respiratory and cardiac complications.
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