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?
Infiltration
Extravasation
Venous spasm
Phlebitis
The Correct Answer is D
A. Infiltration:
Infiltration refers to the inadvertent administration of a non-vesicant solution into the surrounding tissue. It is characterized by swelling, pallor, and coolness at the infusion site, but redness and inflammation along the vein are not typical signs of infiltration.
B. Extravasation:
Extravasation occurs when a vesicant solution (a substance that can cause tissue damage) infiltrates into the surrounding tissue. It can cause tissue damage and necrosis. While inflammation is a concern with extravasation, it is not the primary sign, and redness may occur later.
C. Venous spasm:
Venous spasm involves the constriction of the blood vessel, leading to decreased blood flow. It is not typically associated with redness and inflammation along the vein.
D. Phlebitis:
This is the correct answer. Phlebitis refers to inflammation of a vein, and it is characterized by redness, warmth, and tenderness along the course of the vein. Phlebitis can be caused by various factors, including irritants in the infused solution, mechanical trauma, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer more than one pill to the client at a time: Administering more than one pill at a time may increase the risk of choking, especially for individuals with dysphagia. It's generally advisable to administer one medication at a time to ensure proper swallowing.
B. Tilt the client's head back when administering the medications: Tipping the head backward can increase the risk of aspiration (inhalation of medication into the airways). It is recommended to keep the head in a neutral or slightly forward position to facilitate swallowing.
C. Place the medications on the back of the client's tongue: Placing medications on the back of the tongue may trigger the gag reflex and increase the risk of aspiration. Medications should be placed on the front of the tongue to allow for better control and coordination of swallowing.
D. Mix the medications with a semisolid food for the client (Correct Answer): Mixing medications with a semisolid food, often referred to as "food thickening," can be beneficial for clients with dysphagia. This helps make the medications easier to swallow and reduces the risk of choking or aspiration. However, it is important to check with the healthcare provider or pharmacist to ensure compatibility with specific medications.
Correct Answer is B
Explanation
A. Limit your sodium intake: While excessive sodium intake may be a concern for individuals with certain health conditions, there is no specific restriction on sodium intake associated with theophylline use. This instruction is not directly relevant to theophylline therapy.
B. Avoid caffeinated beverages (Correct Answer): Caffeine can increase the risk of theophylline toxicity by enhancing its effects. Theophylline is metabolized in the liver, and caffeine can interfere with this process. Therefore, it is advisable for individuals taking theophylline to avoid excessive consumption of caffeinated beverages.
C. Take the medication with meals: Theophylline is often prescribed on an empty stomach because food can decrease its absorption. However, the specific recommendation may vary based on the formulation of the medication. It is important to follow the healthcare provider's instructions regarding when to take theophylline in relation to meals.
D. Restrict milk products: There is no general restriction on milk products associated with theophylline use. However, it's important to note that high-fat meals may affect the absorption of theophylline, so individualized instructions from the healthcare provider should be followed.
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