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 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 fever, chills, and malaise.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, not red streaks along the vein path.

C) This choice is correct. The client's symptoms of fever, chills, malaise, and red streaks along the vein path are indicative of sepsis, which is a severe infection that can occur as a complication of IV therapy. Red streaks along the vein path may indicate the spread of infection along the vein.

D) This choice is incorrect because thrombophlebitis does not typically present with symptoms of fever, chills, and malaise. It is associated with tenderness and a palpable, cord-like structure along the vein.

Questions

A. Elevate the client's arm to reduce swelling. B. Apply a warm compress to the insertion site. C. Discontinue the IV infusion immediately. D. Administer an analgesic for pain relief.

Correct Answer is C

Explanation

A) This choice is incorrect because elevating the client's arm may not address the underlying complication of infiltration. The nurse's priority is to discontinue the IV infusion to prevent further complications.

B) This choice is incorrect because applying a warm compress is not the priority action. The nurse should first discontinue the IV infusion to assess the site and determine appropriate interventions.

C) This choice is correct. The client's symptoms of pain, burning, redness, swelling, and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues. The nurse's priority is to discontinue the IV infusion to prevent further complications and assess the site for potential tissue damage.

D) This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

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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 therapy develops a fever, chills, and malaise. The nurse notices red streaks along the vein path. Which complication of IV therapy should the nurse suspect?

Correct Answer is C

Explanation

A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

Correct Answer is C

Explanation

A nurse is caring for a client receiving IV fluids and observes the client experiencing chills, fever, and elevated heart rate. The nurse should suspect which complication of IV therapy?

A client receiving IV therapy complains of pain and burning at the insertion site. The nurse notices the skin turning red and becoming tender. Which action should the nurse take first?

A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

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?

A nurse is preparing to administer an IV medication to a client. Which action is essential to prevent complications during the medication administration?

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 caring for a client with an IV catheter in place for medication administration. The client reports tenderness, redness, and warmth around the insertion site. The nurse observes purulent drainage at the site. Which complication of IV therapy should the nurse suspect?

A client receiving chemotherapy through an IV complains of pain, burning, and swelling around the IV site. The nurse notices the skin turning red and blistering. Which complication of IV therapy should the nurse suspect?