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
The correct answer is choice D.
Choice A rationale:
Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.
Choice B rationale:
Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.
Choice C rationale:
Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.
Choice D rationale:
Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
Correct Answer is D
Explanation
The correct answer is choiced. Location of blood pressure cuff.
Choice A rationale:The systolic blood pressure of 102 mm Hg is within a normal range and does not require clarification.
Choice B rationale:The position of the client, “sitting up in a chair,” is clearly documented and does not need further clarification.
Choice C rationale:The unit of measurement, “mm Hg,” is the standard unit for blood pressure and is correctly documented.
Choice D rationale:The location of the blood pressure cuff is not specified in the documentation. It is important to document whether the blood pressure was taken on the left or right arm, or another location, to ensure accuracy and consistency in future measurements.
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