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 A
Explanation
A. Fever (Correct Answer): An acute infusion reaction to amphotericin B can manifest with symptoms such as fever, chills, and rigors. An elevated body temperature is indicative of a systemic response to the medication and may suggest an infusion reaction.
B. Dry cough: While respiratory symptoms can be associated with amphotericin B infusion reactions, a dry cough is not a specific indicator. Respiratory symptoms may include dyspnea, chest pain, or coughing, but other signs such as fever are more characteristic of an acute infusion reaction.
C. Hyperglycemia: Hyperglycemia is not typically associated with amphotericin B infusion reactions. The side effects of amphotericin B are more commonly related to its antifungal properties and may include renal toxicity, electrolyte imbalances, and infusion-related reactions, but not hyperglycemia.
D. Pedal edema: Pedal edema (swelling of the feet) is not a typical manifestation of an acute amphotericin B infusion reaction. Infusion reactions are more likely to involve systemic symptoms such as fever, chills, and rigors
Correct Answer is ["400"]
Explanation
Step 1: Determine the Total Volume Needed
- Supplied concentration: 300 mg/100 mL
- Prescribed dose: 300 mg
- Total volume needed = 100 mL
Step 2: Convert Time to Hours
- Prescribed infusion time = 15 minutes
- 15 minutes ÷ 60 minutes/hour = 0.25 hours
Step 3: Calculate the Infusion Rate (mL/hr)
- Infusion rate = Total volume (mL) ÷ Time (hours)
- Infusion rate = 100 mL ÷ 0.25 hours
- Infusion rate = 400 mL/hr
The nurse should set the IV pump to deliver cimetidine at 400 mL/hr (rounded to the nearest whole number).
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