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?

Phlebitis

Infiltration

Fluid overload

Air embolism

Answer and Explanation

The Correct Answer is B

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

B) This choice is correct. The client's symptoms of swelling, coolness, and pallor around the insertion site, along with a slowed infusion and discomfort, 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 swelling and coolness around the IV site.

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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. Administering the IV medications rapidly to minimize exposure. B. Consulting with the healthcare provider to switch to oral medications. C. Using a smaller-gauge IV catheter for medication administration. D. Performing a thorough allergy assessment and using allergy alerts.

Correct Answer is D

Explanation

A) This choice is incorrect because administering IV medications rapidly may increase the risk of an allergic reaction, especially in a client with a history of multiple drug allergies.

B) This choice is incorrect because switching to oral medications may not be appropriate or feasible for all IV medications. The nurse should consider alternative medications only after performing a thorough allergy assessment and consulting with the healthcare provider.

C) This choice is incorrect because the choice of IV catheter gauge is not directly related to preventing allergic reactions. It should be based on the medication's compatibility and viscosity.

D) This choice is correct. A thorough allergy assessment is essential in a client with a history of multiple drug allergies to identify potential allergens and prevent exposure to allergenic medications. The nurse should communicate allergies to the healthcare team and document them in the client's medical record, using allergy alerts or wristbands, to ensure safe medication administration.

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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?

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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 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?

Correct Answer is D

Explanation

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