A nurse is caring for a client with a peripheral IV catheter in place. The client complains of tenderness and a palpable, cord-like structure along the vein. The nurse should suspect which complication of IV therapy?
Infiltration
Phlebitis
Fluid overload
Thrombophlebitis
The Correct Answer is D
A) This choice is incorrect because infiltration is characterized by swelling, coolness, and pallor around the insertion site, not a palpable, cord-like structure along the vein.
B) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not a palpable, cord-like structure.
C) This choice is incorrect because fluid overload is not associated with a palpable, cord-like structure along the vein . It may cause generalized edema and increased blood pressure.
D) This choice is correct. The client's symptoms of tenderness and a palpable, cord-like structure along the vein are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The palpable cord-like structure is likely a thrombus within the vein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This choice is correct. The client's symptoms of swelling, redness, and warmth around the insertion site are indicative of phlebitis, which is inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.
B) This choice is incorrect because infiltration refers to the inadvertent administration of IV fluid into the surrounding tissues, causing swelling and coolness around the insertion site.
C) This choice is incorrect because fluid overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and bounding pulse, not local symptoms around the IV site.
D) This choice is incorrect because air embolism occurs when air enters the vascular system, leading to symptoms such as dyspnea, cyanosis, and chest pain, rather than localized symptoms at the insertion site.
Correct Answer is C
Explanation
A) This choice is incorrect because phlebitis and infiltration are not associated with symptoms of shortness of breath, crackles in the lungs, and jugular vein distention.
B) This choice is incorrect because infiltration typically does not cause respiratory symptoms like shortness of breath and crackles in the lungs.
C) This choice is correct. The client's symptoms of shortness of breath, crackles in the lungs (rales), and jugular vein distention are potential signs of fluid overload, which occurs when there is an excessive volume of IV fluids administered.
D) This choice is incorrect because catheter occlusion does not cause respiratory symptoms like those described by the client.
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