A client receiving IV therapy complains of pain and burning at the insertion site. The nurse notices the skin turning red and becoming tender. Which action should the nurse take first?

Stop the IV infusion immediately.

Elevate the arm to promote venous return.

Apply a warm compress to the site for comfort.

Administer a prescribed analgesic.

Answer and Explanation

The Correct Answer is A

A) This choice is correct. The client's symptoms of pain, burning, redness, and tenderness at the insertion site are indicative of a potential complication, such as phlebitis or infiltration. The nurse should stop the IV infusion immediately to prevent further damage.

B) This choice is incorrect because elevating the arm may not address the underlying complication of phlebitis or infiltration.

C) This choice is incorrect because applying a warm compress is not the priority. The nurse should first stop the infusion to prevent complications.

D) This choice is incorrect because administering an analgesic may provide temporary relief, but it does not address the potential complication causing the client's symptoms. The nurse should first stop the IV infusion to assess the site and determine appropriate interventions.

Questions

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Correct Answer is D

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not puncturing the vein. Burning pain is not typically associated with infiltration.

B) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not fluid leakage and burning pain.

C) This choice is incorrect because fluid overload is not related to the puncture of the vein and leakage of IV fluid. Symptoms of fluid overload include dyspnea, elevated blood pressure, and jugular vein distention.

D) This choice is correct. The nurse should suspect extravasation, which occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture. Burning pain and discomfort at the insertion site are common symptoms of extravasation.

A. Changing the IV tubing every 24 hours B. Administering antibiotics prophylactically C. Keeping the IV bag above the level of the heart D. Using a large-gauge catheter

Correct Answer is A

Explanation

A) This choice is correct. Changing the IV tubing every 24 hours is a recommended intervention to reduce the risk of catheter-related bloodstream infections (CRBSIs) by minimizing the accumulation of microorganisms in the tubing.

B) This choice is incorrect because administering antibiotics prophylactically is not a standard practice for preventing CRBSIs, and it can contribute to antibiotic resistance.

C) This choice is incorrect because keeping the IV bag above the level of the heart is a technique used to regulate IV flow rate, but it is not specifically related to preventing CRBSIs.

D) This choice is incorrect because using a large-gauge catheter is not a preventive measure for CRBSIs. The appropriate catheter size should be based on the client's clinical condition and the prescribed therapy.

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A client receiving IV therapy complains of pain and burning at the insertion site. The nurse notices the skin turning red and becoming tender. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

Correct Answer is D

Explanation

A nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?

Correct Answer is A

Explanation

A client receiving IV fluids complains of a cool sensation around the insertion site, and the nurse observes swelling and blanching of the skin. Which complication of IV therapy should the nurse suspect?

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

A client receiving IV fluids develops a fever, tachycardia, and hypotension. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication?

A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?

A nurse is preparing to administer IV medications to a client. What should the nurse do to prevent medication incompatibilities during IV therapy?