A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

Elevate the client's arm to reduce swelling.

Apply a warm compress to the insertion site.

Discontinue the IV infusion immediately.

Administer an analgesic for pain relief.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because elevating the client's arm may not address the underlying complication of infiltration. The nurse's priority is to discontinue the IV infusion to prevent further complications.

B) This choice is incorrect because applying a warm compress is not the priority action. The nurse should first discontinue the IV infusion to assess the site and determine appropriate interventions.

C) This choice is correct. The client's symptoms of pain, burning, redness, swelling, and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues. The nurse's priority is to discontinue the IV infusion to prevent further complications and assess the site for potential tissue damage.

D) This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.

B) This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.

C) This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.

D) This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.

A. Phlebitis B. Infiltration C. Fluid overload D. Catheter occlusion

Correct Answer is B

Explanation

A) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not blanching of the skin.

B) This choice is correct. The client's symptoms of a cool sensation, swelling, and blanching of the skin are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

C) This choice is incorrect because fluid overload is not associated with local symptoms around the insertion site.

D) This choice is incorrect because catheter occlusion may affect the IV flow rate, but it does not typically cause the symptoms described by the client.

View Question and Answer

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

A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving chemotherapy through an IV complains of pain, burning, and swelling around the IV site. The nurse notices the skin turning red and blistering. Which complication of IV therapy should the nurse suspect?

Correct Answer is D

Explanation

A client receiving IV fluids complains of a cool sensation around the insertion site, and the nurse observes swelling and blanching of the skin. Which complication of IV therapy should the nurse suspect?

Correct Answer is B

Explanation

A client receiving IV fluids develops a fever, tachycardia, and hypotension. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A client receiving IV therapy develops a fever, chills, and malaise. The nurse notices red streaks along the vein path. Which complication of IV therapy should the nurse suspect?

A client receiving IV medication complains of sudden chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect?

A client receiving an IV medication suddenly develops generalized hives, facial swelling, and difficulty breathing. The nurse should suspect which type of hypersensitivity reaction?

A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes redness, warmth, and swelling around the insertion site, and the client reports tenderness and pain. Which complication of IV therapy should the nurse suspect?

A nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?