A nurse is caring for a client who is receiving intravenous fluids. The nurse notes the client's skin around their peripheral IV site is taut and edematous. Which of the following complications is the client experiencing?
Infection
Infiltration
Air embolism
Phlebitis
The Correct Answer is B
A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.
B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.
C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.
D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Do you snore loudly?": Loud snoring is a common symptom of sleep apnea, particularly obstructive sleep apnea. The nurse should inquire about snoring, as it may indicate airway obstruction during sleep, a key feature of the condition.
B. "What time do you go to bed?": While bedtime habits are relevant to sleep hygiene, the specific timing of going to bed is not as directly related to diagnosing sleep apnea. Other questions, such as snoring or breathing patterns, are more relevant for this assessment.
C. "How often do you have trouble sleeping?": Trouble sleeping can be a symptom of various sleep disorders, but it is not specific to sleep apnea. The nurse should focus on symptoms like snoring, choking, or stopping breathing during sleep, which are more indicative of sleep apnea.
D. "Do you fall asleep unexpectedly?": Falling asleep unexpectedly may suggest excessive daytime sleepiness, which can be a result of sleep apnea. However, snoring is a more direct and common symptom of sleep apnea that should be prioritized in the initial assessment.
Correct Answer is A
Explanation
A. Occupational therapist: An occupational therapist specializes in helping clients with activities of daily living (ADLs), such as dressing, grooming, and bathing. An occupational therapist can assist in creating strategies or using adaptive equipment to help the client become more independent with dressing.
B. Respiratory therapist: A respiratory therapist focuses on managing respiratory issues and providing treatments like oxygen therapy or breathing exercises. This is not directly related to assisting with dressing, so they are not the appropriate team member for this issue.
C. Social worker: While a social worker can assist with psychosocial issues and discharge planning, they are not typically involved in helping with daily functional tasks like dressing. They would not be the primary provider for this need.
D. Physical therapist: A physical therapist focuses on improving movement, strength, and mobility, particularly related to walking and physical rehabilitation. While they may assist with mobility following surgery, they are not primarily focused on ADLs like dressing.
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