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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fluid restriction: Fluid restriction is not indicated for high serum magnesium levels. It is generally used for conditions like heart failure or renal impairment, but not specifically for managing hypermagnesemia.
B. Furosemide (Lasix): This is the correct choice because furosemide is a diuretic that can help promote the excretion of excess magnesium through the urine. It is an appropriate treatment for hypermagnesemia, which is indicated by the elevated serum magnesium level.
C. Calcium carbonate (Tums): This option is incorrect as calcium carbonate is typically used to treat hypomagnesemia (low magnesium levels) or to bind excess phosphate, not to manage elevated magnesium levels.
D. Magnesium oxide (MagOx): This is not suitable because magnesium oxide would increase the magnesium level further, not decrease it. It is used to supplement magnesium in cases of deficiency, not to treat hypermagnesemia.
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.
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