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 A

Explanation

A) This choice is correct. The client's symptoms of swelling, redness, and warmth around the insertion site are indicative of phlebitis, which is inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.

B) This choice is incorrect because infiltration refers to the inadvertent administration of IV fluid into the surrounding tissues, causing swelling and coolness around the insertion site.

C) This choice is incorrect because fluid overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and bounding pulse, not local symptoms around the IV site.

D) This choice is incorrect because air embolism occurs when air enters the vascular system, leading to symptoms such as dyspnea, cyanosis, and chest pain, rather than localized symptoms at the insertion site.

A. Use the same insertion site for all IV catheter changes. B. Change the IV catheter every 72 hours as per policy. C. Rotate the IV insertion site with each catheter change. D. Administer medications in large volumes to minimize insertion frequency.

Correct Answer is C

Explanation

A) This choice is incorrect because using the same insertion site for all IV catheter changes can lead to complications such as phlebitis and infiltration due to repetitive trauma to the vein.

B) This choice is incorrect because changing the IV catheter every 72 hours as per policy may not be necessary unless the catheter is no longer functioning properly or the site shows signs of complications. Changing the catheter prematurely can increase the risk of complications.

C) This choice is correct. Rotating the IV insertion site with each catheter change helps to distribute the risk of complications across multiple sites and allows previously used sites time to heal and recover.

D) This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.

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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 assessing a client who has an IV catheter in place for fluid administration. The nurse observes swelling, redness, and warmth around the insertion site. Which complication of IV therapy should the nurse suspect?

Correct Answer is A

Explanation

A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

Correct Answer is C

Explanation

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