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?

Changing the IV tubing every 24 hours

Administering antibiotics prophylactically

Keeping the IV bag above the level of the heart

Using a large-gauge catheter

Answer and Explanation

The Correct Answer is A

A) This choice is correct. Changing the IV tubing every 24 hours is a recommended intervention to reduce the risk of catheter-related bloodstream infections (CRBSIs) by minimizing the accumulation of microorganisms in the tubing.

B) This choice is incorrect because administering antibiotics prophylactically is not a standard practice for preventing CRBSIs, and it can contribute to antibiotic resistance.

C) This choice is incorrect because keeping the IV bag above the level of the heart is a technique used to regulate IV flow rate, but it is not specifically related to preventing CRBSIs.

D) This choice is incorrect because using a large-gauge catheter is not a preventive measure for CRBSIs. The appropriate catheter size should be based on the client's clinical condition and the prescribed therapy.

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Correct Answer is C

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not redness, warmth, and tenderness around the insertion site.

B) This choice is incorrect because extravasation occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture, but it does not present with redness and swelling.

C) This choice is correct. The client's symptoms of redness, warmth, swelling, tenderness, and pain around the insertion site are indicative of phlebitis, which is the inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.

D) This choice is incorrect because an air embolism is not associated with symptoms of phlebitis, such as redness and swelling around the IV site.

A. Discontinue the IV medication immediately. B. Administer an antihistamine to relieve the symptoms. C. Notify the healthcare provider about the localized reaction. D. Elevate the arm to reduce the swelling at the IV site.

Correct Answer is A

Explanation

A) This choice is correct. The client's localized symptoms of swelling, erythema, and pain at the IV site may indicate a local allergic reaction or chemical irritation. The nurse should discontinue the IV medication immediately to prevent the progression of the reaction and assess the client further for any systemic signs of an allergic reaction.

B) This choice is not the priority action. While administering an antihistamine may relieve symptoms of an allergic reaction, the nurse's priority is to discontinue the IV medication and assess the client's condition.

C) This choice is not the priority action. While notifying the healthcare provider is important, the nurse's immediate priority is to discontinue the IV medication and assess the client's condition.

D) This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A client receiving an IV medication develops localized swelling, erythema, and pain at the IV site. The nurse assesses the client's vital signs and finds no signs of systemic allergic reaction. What is the nurse's priority action?

Correct Answer is A

Explanation

A client receiving IV medications develops a painful, warm, and red streak along the arm near the IV site. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A nurse is preparing to administer an IV medication to a client. Which action is essential to prevent complications during the medication administration?

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 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 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?

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 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?

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?