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. The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.
Correct Answer is C
Explanation
The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.
This can help alleviate dyspnea and improve oxygenation in clients with heart failure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today