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.

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Correct Answer is C

Explanation

A) This choice is incorrect because the client's preference for IV therapy over oral fluids is not a valid indication for initiating IV therapy. Clinical indications should guide the decision, not personal preferences.

B) This choice is incorrect because a history of IV drug use does not automatically indicate a need for IV therapy for dehydration. The client's current condition and clinical status should determine the need for IV fluids.

C) This choice is correct. In cases of severe dehydration where the client is unable to tolerate oral intake, IV therapy is essential to provide rapid rehydration and restore fluid and electrolyte balance.

D) This choice is incorrect because the family's request alone is not a sufficient indication for initiating IV therapy. The decision should be based on the client's clinical condition and medical needs.

A. Infiltration B. Phlebitis C. Infection D. Thrombophlebitis

Correct Answer is C

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with purulent drainage and redness.

B) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, but it does not cause purulent drainage.

C) This choice is correct. The client's symptoms of tenderness, redness, warmth, and purulent drainage around the insertion site are indicative of an infection, which can occur as a complication of IV therapy if bacteria enter the bloodstream through the catheter.

D) This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.

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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 nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

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?

A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client's vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?

A client with chronic kidney disease is receiving IV therapy with a potassium-containing solution. The nurse should carefully monitor the client for which complication?

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?

A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

A client with a history of heart failure is receiving IV fluids. The nurse should closely monitor the client for which potential complication?