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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) This choice is incorrect because administering IV fluids through the largest available catheter is not necessary for preventing CRBSIs. The appropriate catheter size should be based on the client's clinical needs and the prescribed therapy.

B) This choice is incorrect because changing the IV catheter dressing daily is not necessarily recommended unless the dressing is soiled or loose. Frequent dressing changes can increase the risk of contamination and infection. The nurse should follow evidence-based guidelines for catheter care and dressing changes.

C) This choice is correct. Using sterile technique during IV insertion and care is essential for preventing CRBSIs. Sterile technique helps to reduce the risk of introducing pathogens into the bloodstream, which can lead to infection.

D) This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.

A. Administer the medication as prescribed. B. Withhold the medication and notify the healthcare provider. C. Ask the client to rate the severity of the itchiness. D. Administer an antihistamine before giving the medication.

Correct Answer is B

Explanation

A) This choice is incorrect because administering the medication as prescribed may exacerbate the allergic reaction and is not safe without further assessment and medical guidance.

B) This choice is correct. The client's statement about being allergic to penicillin and experiencing itchiness in the throat suggests a potential allergic reaction. The nurse should withhold the medication and promptly notify the healthcare provider to assess the client's allergic response and determine an alternative course of action.

C) This choice is not the priority action. While assessing the severity of the itchiness is important, the nurse's priority is to withhold the medication and notify the healthcare provider about the potential allergic reaction.

D) This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

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