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 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.
Correct Answer is D
Explanation
A) This choice is incorrect because phlebitis does not present with symptoms of dyspnea, chest pain, and cyanosis.
B) This choice is incorrect because infiltration does not cause sudden onset dyspnea, chest pain, and cyanosis. Infiltration involves localized symptoms around the insertion site.
C) This choice is incorrect because fluid overload does not typically cause sudden onset dyspnea, chest pain, and cyanosis.
D) This choice is correct. The client's symptoms of sudden onset dyspnea, chest pain, and cyanosis are indicative of a pulmonary embolism, which occurs when a blood clot travels to the lungs. This can be a life-threatening complication of IV therapy, especially in clients receiving antibiotics who are at higher risk for clot formation.
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