A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

Use the same insertion site for all IV catheter changes.

Change the IV catheter every 72 hours as per policy.

Rotate the IV insertion site with each catheter change.

Administer medications in large volumes to minimize insertion frequency.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because using the same insertion site for all IV catheter changes can lead to complications such as phlebitis and infiltration due to repetitive trauma to the vein.

B) This choice is incorrect because changing the IV catheter every 72 hours as per policy may not be necessary unless the catheter is no longer functioning properly or the site shows signs of complications. Changing the catheter prematurely can increase the risk of complications.

C) This choice is correct. Rotating the IV insertion site with each catheter change helps to distribute the risk of complications across multiple sites and allows previously used sites time to heal and recover.

D) This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.

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Correct Answer is C

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with warmth and swelling along the vein path.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause tenderness, warmth, and swelling along the vein path.

C) This choice is correct. The client's symptoms of tenderness, warmth, and swelling along the vein path are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can cause obstruction along the vein path, leading to the symptoms described by the client.

D) This choice is incorrect because sepsis typically presents with systemic symptoms like fever, chills, and confusion, not localized symptoms along the vein path.

Questions

A. Phlebitis B. Air embolism C. Fluid overload D. Infiltration

Correct Answer is B

Explanation

A) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness and warmth, not shortness of breath, chest pain, and rapid heart rate.

B) This choice is correct. The client's symptoms of shortness of breath, chest pain, and rapid heart rate suggest an air embolism, which occurs when air enters the bloodstream through the IV catheter. This is a medical emergency, and the nurse should take immediate action to protect the client's airway, administer oxygen, and notify the healthcare provider.

C) This choice is incorrect because fluid overload is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate. It is characterized by symptoms such as edema and elevated blood pressure.

D) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate.

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A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

Correct Answer is C

Explanation

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?

Correct Answer is B

Explanation

A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

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A client receiving IV antibiotics develops sudden onset dyspnea, chest pain, and cyanosis. The nurse should suspect which complication of IV therapy?

A nurse is assessing a client who has an IV catheter in place for fluid administration. The nurse observes swelling, redness, and warmth around the insertion site. Which complication of IV therapy should the nurse suspect?

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A client with a history of heart failure is receiving IV fluids. The nurse should closely monitor the client for which potential complication?