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 B

Explanation

A. Midazolam (Versed): This is a benzodiazepine used for sedation. It is not typically used in the post-anesthesia care unit unless there is a need for additional sedation or anxiolysis, which is not indicated based on the scenario.
B. Naloxone (Narcan): This is the correct choice. Naloxone is used to reverse opioid-induced respiratory depression. If the vital signs indicate respiratory depression or decreased oxygen saturation potentially due to opioid medications used during surgery, naloxone would be administered.
C. Atropine (Atropen): This medication is used to treat bradycardia (slow heart rate) and is not typically indicated based on vital signs trends without specific symptoms.
D. Dantrolene (Dantrium): This medication is used to treat malignant hyperthermia, a rare but serious condition often triggered by certain anesthetics. It would be indicated if there were signs of this condition, such as a high fever and muscle rigidity, which is not mentioned in the scenario.

A. Blood in the tubing close to the insertion site B. Chills, fever, and generalized discomfort C. Pallor, sweating, and discomfort at the insertion site D. Dyspnea, headache, and increased blood pressure

Correct Answer is D

Explanation

A. Blood in the tubing close to the insertion site: This indicates a possible issue with the IV but not fluid overload specifically.
B. Chills, fever, and generalized discomfort: These symptoms may suggest an infection or reaction but are not specific to fluid overload.
C. Pallor, sweating, and discomfort at the insertion site: These could indicate a local reaction or issue with the IV site but not fluid overload.
D. Dyspnea, headache, and increased blood pressure: These symptoms are indicative of fluid overload, as the body reacts to excessive fluid with symptoms such as difficulty breathing (dyspnea), increased blood pressure, and headaches.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

Correct Answer is D

Explanation

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