After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

Infiltration

Phlebitis

Extravasation

Infection

- E. Limited ambulation

Answer and Explanation

The Correct Answer is B

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

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Correct Answer is A

Explanation

A. Warfarin (Coumadin): This is the correct choice. Warfarin is an anticoagulant that increases the risk of bleeding during and after surgery. The surgeon needs to be notified to consider holding the medication and to adjust the surgical plan if necessary.
B. Gabapentin (Neurontin): While important for pain management, it does not significantly impact surgical procedures or bleeding risk.
C. Xanax (Alprazolam): This medication is a benzodiazepine used for anxiety, which might be relevant for preoperative anxiety but does not require immediate notification of the surgeon.
D. Atenolol (Tenormin): This beta-blocker is used for hypertension and heart conditions but does not require immediate notification of the surgeon unless there are specific cardiac concerns related to surgery.

A. Deep breathing and coughing exercises daily B. Removal of compression stockings at night C. Floating the heels while lying in bed D. Leg exercises ten times per hour while awake

Correct Answer is D

Explanation

A. Deep breathing and coughing exercises daily: These are important for preventing respiratory complications but do not specifically address the prevention of thrombosis.
B. Removal of compression stockings at night: Compression stockings should generally be worn continuously to prevent venous stasis and thrombosis.
C. Floating the heels while lying in bed: This helps prevent pressure ulcers but is not a primary intervention for preventing thrombosis.
D. Leg exercises ten times per hour while awake: This is the correct choice. Regular leg exercises improve circulation and help prevent venous stasis, thereby reducing the risk of thrombosis.

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After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

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Correct Answer is A

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Explanation

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