A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

Applying a warm compress to the IV site.

Limiting the use of the affected arm for IV insertion.

Avoiding the use of a tourniquet during IV insertion.

Selecting a small-gauge catheter for the IV insertion.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.

B) This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.

C) This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.

D) This choice is incorrect because selecting a small-gauge catheter is not the primary intervention to prevent thrombophlebitis in a client with a history of DVT. The choice of catheter size should be based on the client's clinical needs and vein condition.

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Correct Answer is D

Explanation

A) This choice is incorrect because phlebitis does not present with symptoms of dyspnea, chest pain, and cyanosis.

B) This choice is incorrect because infiltration does not cause sudden onset dyspnea, chest pain, and cyanosis. Infiltration involves localized symptoms around the insertion site.

C) This choice is incorrect because fluid overload does not typically cause sudden onset dyspnea, chest pain, and cyanosis.

D) This choice is correct. The client's symptoms of sudden onset dyspnea, chest pain, and cyanosis are indicative of a pulmonary embolism, which occurs when a blood clot travels to the lungs. This can be a life-threatening complication of IV therapy, especially in clients receiving antibiotics who are at higher risk for clot formation.

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

Correct Answer is B

Explanation

A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not coolness.

B) This choice is correct. The client's symptoms of swelling and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

C) This choice is incorrect because fluid overload is not associated with localized symptoms like swelling and coolness at the IV site.

D) This choice is incorrect because an air embolism is not associated with symptoms of swelling and coolness at the IV site.

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A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect?

Correct Answer is B

Explanation

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes swelling, coolness, and pallor around the insertion site. The infusion has slowed, and the client reports discomfort. Which complication of IV therapy should the nurse suspect?

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?

A client receiving IV fluids suddenly experiences shortness of breath, crackles in the lungs, and jugular vein distention. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A nurse is caring for a client with a history of multiple drug allergies who requires IV therapy. Which intervention is essential to prevent an allergic reaction in this client?

A client receiving an IV medication suddenly develops generalized hives, facial swelling, and difficulty breathing. The nurse should suspect which type of hypersensitivity reaction?

A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. The nurse should suspect which complication of IV therapy?

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?