A nurse is caring for a client who is receiving intravenous therapy and observes redness and inflammation along the vein. The nurse should identify this finding as which of the following complications of IV therapy?

Extravasation

Phlebitis

Infiltration

Venous spasm

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Extravasation is incorrect. This occurs when the intravenous fluid leaks into the surrounding tissue rather than remaining within the vein. It may cause swelling, pain, and potential tissue damage due to the infused solution's irritant effects.
Choice B Reason:
Phlebitis is correct. Phlebitis refers to the inflammation of a vein often characterized by redness, warmth, swelling, and tenderness along the course of the vein. It can occur due to various reasons, including irritation from the IV catheter, chemical irritation from the infused solution, or infection.
Choice C Reason:
Infiltration is incorrect. Infiltration refers to the inadvertent leakage of the infused fluid into the surrounding tissues. It may cause swelling and discomfort but doesn't typically present with redness and inflammation along the vein.
Choice D Reason:
Venous spasm is incorrect. Venous spasm involves the involuntary contraction of the vein, which can occur in response to irritation or trauma. It may cause temporary difficulty in IV access but does not usually present with redness and inflammation along the vein as the primary signs.

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Correct Answer is C

Explanation

Choice A Reason:
"I should avoid drinking grapefruit juice." This statement is actually accurate. Grapefruit juice can interfere with the metabolism of certain statin medications, including lovastatin, leading to increased levels of the drug in the body. Advising against grapefruit juice consumption is a recommended precaution when taking lovastatin, so this statement shows the client's understanding of this interaction.
Choice B Reason:
"I am trying to decrease my dietary fat intake." This statement reflects a positive lifestyle change. Lowering dietary fat intake is often recommended for individuals on statin medications to help manage cholesterol levels. This statement demonstrates the client's commitment to making healthy dietary adjustments, which aligns with the treatment plan.
Choice B Reason:
"I was just diagnosed with hepatitis B. "Hepatitis B can affect liver function, and statin medications like lovastatin can potentially impact liver enzymes. Therefore, in someone with a history of hepatitis B, it's crucial to assess liver function before starting a statin and to monitor the liver during treatment. This statement raises concerns about potential liver complications or interactions that require further evaluation before initiating lovastatin.
Choice D Reason:
"I take metformin for my diabetes." Metformin, a medication for diabetes, does not directly interact with lovastatin. While it's relevant to know the client's other medications, this statement doesn't indicate a need for immediate further assessment regarding the use of lovastatin.

A. Discard the medication if it is yellow. B. Administer the medication over 2 hr. C. Use a gravity flow set. D. Prime the tubing with 0.9% sodium chloride.

Correct Answer is D

Explanation

Choice A Reason:
Discard the medication if it is yellow is incorrect. While amphotericin B lipid complex can have a yellowish color, it's important to follow specific guidelines provided by the manufacturer or pharmacy regarding any discoloration or changes in the medication's appearance. Discoloration could indicate degradation or contamination, and it's crucial to adhere to specific institutional policies in such cases.
Choice B Reason:
Administer the medication over 2 hr is incorrect. Amphotericin B lipid complex is usually given over a longer duration (e.g., several hours) due to the potential for infusion-related reactions. Intermittent IV bolus administration over 2 hours might not be appropriate and can increase the risk of adverse reactions.
Choice C Reason:
Use a gravity flow set is incorrect. For medications like amphotericin B lipid complex, which often require precise infusion rates and careful monitoring, using an IV infusion pump is usually recommended instead of a gravity flow set. An infusion pump allows for more accurate control of the infusion rate and reduces the risk of errors.
Choice D Reason:
Prime the tubing with 0.9% sodium chloride is correct. Amphotericin B lipid complex should be administered according to specific instructions and precautions. Priming the IV tubing with 0.9% sodium chloride helps ensure that the medication is effectively delivered to the patient and that the medication is not affected by remnants of previous IV solutions in the tubing.

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A nurse is caring for a client who is receiving intravenous therapy and observes redness and inflammation along the vein. The nurse should identify this finding as which of the following complications of IV therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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