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. Visual disturbances:
Visual disturbances, such as blurred or yellow-tinted vision, are common signs of digoxin toxicity. Clients should report any changes in vision promptly.
B. Potassium 4.4 mEq/L:
While electrolyte imbalances, particularly low potassium levels, can increase the risk of digoxin toxicity, a potassium level of 4.4 mEq/L is within the normal range and, by itself, does not indicate digoxin toxicity.
C. Insomnia:
Insomnia is not a typical sign of digoxin toxicity. Symptoms of toxicity are more likely to involve the gastrointestinal and visual systems.
D. Sudden weight gain:
Sudden weight gain can be a symptom of heart failure exacerbation but is not a direct indication of digoxin toxicity. Other signs, such as visual disturbances, are more specific to digoxin toxicity.
Correct Answer is D
Explanation
A. "If I were you, I would get the vaccine to keep my family safe:"
This statement imposes the nurse's personal opinion on the client and may not respect the client's autonomy and decision-making.
B. "Influenza can be very serious to anyone who does not receive the vaccine:"
While this statement conveys the seriousness of influenza, it may be perceived as coercive or fear-inducing. It is important to provide information without pressure.
C. "The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form:"
This statement is not accurate and may create unnecessary tension. Influenza vaccination is generally not mandatory, and clients have the right to decline without being labeled against medical advice for this particular vaccination.
D. "The influenza vaccine is strongly encouraged, but I understand you would like to decline right now:"
This is the correct answer. It acknowledges the client's decision to decline the vaccine while expressing that the vaccine is encouraged. It respects the client's autonomy and allows for open communication about the decision.
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