A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking.
The nurse should identify that the client has manifestations of which of the following complications?
Phlebitis.
Infection.
Infiltration.
Circulatory overload.
The Correct Answer is C
Choice A rationale:
Phlebitis is inflammation of a vein, often associated with pain, redness, and warmth at the catheter site. In this case, the client's catheter site is described as cool and taut, which is not consistent with the manifestations of phlebitis.
Choice B rationale:
Infection typically presents with signs such as redness, warmth, swelling, and pain at the catheter site. The description of the client's catheter site as cool and taut is not indicative of infection.
Choice C rationale:
The client's symptoms, including a cool and taut catheter site and IV fluid leaking, are indicative of infiltration. Infiltration occurs when IV fluids inadvertently enter the surrounding tissue instead of the vein. It can lead to localized swelling and discomfort.
Choice D rationale:
Circulatory overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and tachycardia. These symptoms are not consistent with the client's description of a cool and taut catheter site with IV fluid leaking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Protecting a client's safety by not causing harm refers to the ethical principle of nonmaleficence. Nonmaleficence emphasizes the duty of healthcare professionals to avoid harm or minimize harm when providing care to clients. This principle is closely related to the concept of "do no harm" and places a high value on the well-being and safety of the client. Nurses must make decisions and take actions that prioritize the client's safety and well-being, even when faced with difficult ethical dilemmas.
Choice A rationale:
Beneficence is the ethical principle that emphasizes doing good and promoting the well-being of the client. While it is an essential ethical principle in nursing, it is not directly related to the concept of not causing harm, as described in the question.
Choice B rationale:
Fidelity, also known as faithfulness or loyalty, pertains to the nurse's obligation to uphold commitments and keep promises made to the client. While fidelity is crucial in nursing practice, it is not the primary principle related to the concept of not causing harm.
Choice C rationale:
Justice is the ethical principle concerned with fairness and the equitable distribution of healthcare resources and treatment. It focuses on providing clients with their due and ensuring that they are treated fairly and without discrimination. Justice is important in healthcare ethics but is not directly associated with the principle of not causing harm.
Correct Answer is C
Explanation
Choice C rationale:
Respite care provides support for a client's caregiver. Respite care offers temporary relief or rest for caregivers who are taking care of individuals with chronic illness, disabilities, or those approaching the end of life. It allows caregivers to have a break from their responsibilities, reducing caregiver burnout and stress. This type of support helps maintain the caregiver's physical and emotional well-being, which, in turn, benefits the client's overall care.
Choice A rationale:
Postmortem care is the care provided to a deceased client, and it does not directly support the caregiver of a living client. It is essential for ensuring respectful and appropriate handling of the deceased individual but does not provide support to caregivers.
Choice B rationale:
Home care involves healthcare services delivered in the client's home, which can be beneficial for the client's care but does not specifically address the needs of the caregiver. While it may indirectly ease the caregiver's responsibilities, it is not a service designed to support caregivers directly.
Choice D rationale:
Restorative care focuses on rehabilitation and restoring the client's health and independence, which primarily benefits the client rather than the caregiver. It is not a service aimed at supporting caregivers in the same way that respite care does.
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