A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. The nurse should suspect which complication of IV therapy?
Infiltration
Phlebitis
Infection
Thrombophlebitis
The Correct Answer is C
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 localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause purulent drainage.
C) This choice is correct. The client's symptoms of pain, redness, and purulent drainage at the IV site are indicative of an infection, which can occur as a complication of IV therapy, especially in clients with diabetes who may have compromised immune systems.
D) This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not blanching of the skin.
B) This choice is correct. The client's symptoms of a cool sensation, swelling, and blanching of the skin 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 local symptoms around the insertion site.
D) This choice is incorrect because catheter occlusion may affect the IV flow rate, but it does not typically cause the symptoms described by the client.
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.
B) This choice is correct. The client's symptoms of swelling and coolness around the insertion site 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 swelling and coolness at the IV site.
D) This choice is incorrect because an air embolism is not associated with symptoms of swelling and coolness at the IV site.
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