A nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

Infiltration

Phlebitis

Fluid overload

Extravasation

Answer and Explanation

The Correct Answer is D

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not puncturing the vein. Burning pain is not typically associated with infiltration.

B) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not fluid leakage and burning pain.

C) This choice is incorrect because fluid overload is not related to the puncture of the vein and leakage of IV fluid. Symptoms of fluid overload include dyspnea, elevated blood pressure, and jugular vein distention.

D) This choice is correct. The nurse should suspect extravasation, which occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture. Burning pain and discomfort at the insertion site are common symptoms of extravasation.

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Correct Answer is D

Explanation

A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.

B) This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.

C) This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.

D) This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.

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

Correct Answer is C

Explanation

A) This choice is incorrect because infiltration is not directly related to the client's history of heart failure.

B) This choice is incorrect because phlebitis is not specifically associated with heart failure but rather with irritants in the IV solution or mechanical trauma.

C) This choice is correct. Clients with a history of heart failure are at an increased risk of fluid overload due to their compromised cardiac function. Monitoring for signs of fluid overload, such as dyspnea, jugular vein distention, and peripheral edema, is essential during IV therapy.

D) This choice is incorrect because an air embolism is not directly related to the client's history of heart failure.

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A nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client with a history of heart failure is receiving IV fluids. The nurse should closely monitor the client for which potential complication?

Correct Answer is C

Explanation

A nurse is assessing a client receiving IV fluids and notes the presence of fever, chills, and confusion. The client's blood pressure is low, and the skin appears mottled. The nurse should recognize these symptoms as potential signs of which complication?

A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?

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

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication?

A nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?

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?