A nurse is caring for a client with an IV catheter in place for fluid administration. The nurse observes the client's arm is edematous, and the skin feels cool to the touch. The infusion is sluggish, and the client reports discomfort at the site. Which complication of IV therapy should the nurse suspect?
Phlebitis
Infiltration
Fluid overload
Air embolism
The Correct Answer is B
A) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not edema and coolness.
B) This choice is correct. The client's symptoms of edema, coolness, sluggish infusion, and discomfort at the 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 those described by the client.
D) This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as edema and coolness around the IV site.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A) This choice is incorrect because infiltration is not typically associated with symptoms of chest pain, difficulty breathing, decreased blood pressure, and weak pulse.
B) This choice is incorrect because phlebitis does not cause sudden onset chest pain, difficulty breathing, decreased blood pressure, and weak pulse.
C) This choice is incorrect because fluid overload is not associated with symptoms like chest pain and decreased blood pressure. It may cause elevated blood pressure due to increased fluid volume.
D) This choice is correct. The client's symptoms of sudden chest pain, difficulty breathing, decreased blood pressure, and weak pulse are indicative of anaphylaxis, a severe allergic reaction. Anaphylaxis can occur in response to an allergen in the IV fluid or medication and can be life-threatening if not treated promptly.
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