A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

Administering IV fluids through the largest available catheter.

Changing the IV catheter dressing daily.

Using sterile technique during IV insertion and care.

Frequently accessing the IV catheter for blood draws.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because administering IV fluids through the largest available catheter is not necessary for preventing CRBSIs. The appropriate catheter size should be based on the client's clinical needs and the prescribed therapy.

B) This choice is incorrect because changing the IV catheter dressing daily is not necessarily recommended unless the dressing is soiled or loose. Frequent dressing changes can increase the risk of contamination and infection. The nurse should follow evidence-based guidelines for catheter care and dressing changes.

C) This choice is correct. Using sterile technique during IV insertion and care is essential for preventing CRBSIs. Sterile technique helps to reduce the risk of introducing pathogens into the bloodstream, which can lead to infection.

D) This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.

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Correct Answer is D

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, confusion, and low blood pressure.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, confusion, and low blood pressure.

C) This choice is incorrect because fluid overload is not associated with symptoms of fever, chills, and confusion. It may cause elevated blood pressure and edema.

D) This choice is correct. The client's symptoms of fever, chills, confusion, low blood pressure, and mottled skin are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.

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

Correct Answer is C

Explanation

A) This choice is incorrect because phlebitis and infiltration are not associated with symptoms of shortness of breath, crackles in the lungs, and jugular vein distention.

B) This choice is incorrect because infiltration typically does not cause respiratory symptoms like shortness of breath and crackles in the lungs.

C) This choice is correct. The client's symptoms of shortness of breath, crackles in the lungs (rales), and jugular vein distention are potential signs of fluid overload, which occurs when there is an excessive volume of IV fluids administered.

D) This choice is incorrect because catheter occlusion does not cause respiratory symptoms like those described by the client.

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A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client receiving IV fluids and notes the presence of fever, chills, and confusion. The client's blood pressure is low, and the skin appears mottled. The nurse should recognize these symptoms as potential signs of which complication?

Correct Answer is D

Explanation

A client receiving IV fluids suddenly experiences shortness of breath, crackles in the lungs, and jugular vein distention. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

Correct Answer is C

Explanation

A nurse is caring for a client receiving IV fluids and observes the client experiencing chills, fever, and elevated heart rate. The nurse should suspect which complication of IV therapy?

A client receiving IV therapy complains of pain and burning at the insertion site. The nurse notices the skin turning red and becoming tender. Which action should the nurse take first?

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

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

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 with a history of multiple drug allergies who requires IV therapy. Which intervention is essential to prevent an allergic reaction in this client?

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?