A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
Nerve damage
Infection
Infiltration
Phlebitis
The Correct Answer is C
Choice A Reason:
Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.
Choice B Reason:
Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.
Choice C Reason:
Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.
Choice D Reason:
Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Discarding soiled wound care supplies in a trash receptacle outside the client's room is generally a good practice for infection control. However, this action alone might not be sufficient for managing an infectious wound. Proper disposal is essential, but placing the client in isolation is more critical to prevent the spread of infection.
Choice B Reason:
Administering antibiotic therapy before culturing the wound might interfere with accurate culture results. It's generally preferred to obtain wound cultures before starting antibiotic therapy to identify the specific pathogens causing the infection and determine the most effective treatment.
Choice C Reason:
Placing the client in a private room with a private bathroom is correct. Isolating the client in a private room with a private bathroom helps minimize the spread of potential pathogens present in the wound drainage. This measure helps contain the infection and prevents exposure to others.
Choice D Reason:
Instructing visitors to perform hand hygiene for only 5 seconds after leaving the client's room isn't thorough enough for proper infection control. Proper hand hygiene typically involves washing hands with soap and water or using alcohol-based hand sanitizer for at least 20 seconds to effectively reduce the spread of infection.
Correct Answer is B, A, C, E, D
Explanation
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.
Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.
Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.
Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.
Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.
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