A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?
Infiltration
Extravasation
Circulatory overload
Phlebitis
The Correct Answer is D
Choice A reason:
Infiltration is not correct: Infiltration occurs when the infused fluid or medication leaks into the surrounding tissue instead of flowing into the vein. This can lead to swelling, coolness, and pallor around the insertion site.
Choice B reason:
Extravasation is not correct: Extravasation is similar to infiltration but specifically refers to the infiltration of vesicant medications, which can cause tissue damage and necrosis.
Choice C reason:
Circulatory overload is not correct: Circulatory overload occurs when a large volume of fluid is infused too quickly, overloading the circulatory system and potentially leading to fluid overload, pulmonary edema, and other related symptoms.
Choice D reason:
Phlebitis is the appropriate fingings. The nurse should document the finding of redness and warmth around the peripheral catheter insertion site as phlebitis. Phlebitis is the inflammation of a vein, often caused by mechanical irritation, chemical irritation, or infection. In this case, the redness and warmth at the insertion site are indicative of inflammation, which is a common sign of phlebitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.
Correct Answer is D
Explanation
Choice A reason:
Being honest with the parents of a child about the need to report suspected abuse is not the correct option. This option involves honesty and ethical responsibility but does not pertain to the fair distribution of resources or benefits.
Choice B reason
Keeping a promise to visit with a client who is housebound after the delivery of care is not the appropriate option. While keeping promises is an ethical principle, it is not related to the fair distribution of resources or benefits.
Choice C reason:
Accepting the decision of an older adult client to live alone in her home is not the correct option. Respecting a client's autonomy and right to make decisions about their living arrangements is an ethical principle, but it is not directly related to distributive justice.
Choice D reason:
The ethical principle of distributive justice is about fair and equitable distribution of resources and benefits within a society or group. It emphasizes providing equal access to services and resources to all individuals, especially those who are vulnerable or marginalized. In this context, the nurse demonstrates distributive justice by ensuring that a homeless client receives preventive medical care, which means they are being provided with necessary health resources and services that might otherwise be challenging for them to access due to their disadvantaged situation.
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