A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?
Thrombophlebitis
Infiltration
Infection
Extravasation
The Correct Answer is A
Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.
Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.
Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.
Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Prolonging the life of a client is not the primary focus of palliative care. While palliative care can sometimes extend life by improving overall well-being and reducing stress, its main goal is to enhance the quality of life by managing symptoms and providing comfort12. Palliative care is not primarily aimed at life extension but rather at ensuring that patients live as well as possible despite their illness.
Choice B Reason:
Controlling symptoms and providing comfort is the core focus of palliative care. This type of care aims to alleviate pain and other distressing symptoms, such as nausea, shortness of breath, and fatigue12. Palliative care also addresses emotional, social, and spiritual needs, helping patients and their families cope with the challenges of serious illness. By focusing on comfort and quality of life, palliative care supports patients in living as fully as possible.
Choice C Reason:
Replacing other treatments for an illness is not the focus of palliative care. Palliative care is designed to complement, not replace, other medical treatments12. It can be provided alongside curative or life-prolonging treatments, offering additional support to manage symptoms and improve quality of life. The goal is to provide a holistic approach to care that addresses all aspects of a patient’s well-being.
Choice D Reason:
Curing a serious illness is not the aim of palliative care. Palliative care is appropriate for patients at any stage of a serious illness, whether or not a cure is possible12. Its primary focus is on symptom management, comfort, and quality of life, rather than on curing the illness. This approach helps patients and their families navigate the complexities of serious health conditions with greater ease and support.
Correct Answer is C
Explanation
Choice A Reason:
A client who is 3 days postoperative and has a nursing assistant helping him out of bed is at some risk for falls due to recent surgery and potential weakness. However, the presence of a nursing assistant reduces this risk significantly. Postoperative clients are often monitored closely and assisted with mobility to prevent falls.
Choice B Reason:
An adolescent client who has a leg fracture and has been using crutches for the past 2 weeks is at risk for falls due to the use of crutches and limited mobility. However, adolescents generally have better balance and coordination compared to older adults, and they adapt quickly to using mobility aids.
Choice C Reason:
An older adult client who is confused and has urinary frequency is at the greatest risk for falls. Confusion can lead to disorientation and poor judgment, increasing the likelihood of falls. Urinary frequency can cause the client to rush to the bathroom, further increasing fall risk. Older adults also tend to have decreased strength and balance, compounding the risk.
Choice D Reason:
A client with diabetes mellitus who has a leg ulcer is at risk for falls due to potential neuropathy and impaired mobility. However, this risk is generally lower compared to a confused older adult with urinary frequency. The leg ulcer may cause some mobility issues, but it does not typically lead to the same level of disorientation and urgency as urinary frequency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today