While assessing a client's peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation?
Air embolism
Phlebitis
Infiltration
Fluid overload
The Correct Answer is C
A. Air embolism involves respiratory distress and is unrelated to local IV site findings.
B. Phlebitis presents with redness, warmth, pain, and sometimes a palpable cord, not coolness.
C. Infiltration occurs when IV fluid leaks into surrounding tissue causing edema and coolness at the site.
D. Fluid overload is a systemic condition, not localized to the IV site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While foot ulcers can be painful, diabetic polyneuropathy often causes loss of sensation, making ulcers less noticeable rather than more painful.
B. Preventing foot ulcers is critical because complications can lead to infections, amputations, and loss of mobility, potentially resulting in institutionalization; maintaining foot health supports independent living.
C. Hypoglycemia and fall risk are valid concerns in diabetes but are not directly related to foot care.
D. Oral antihyperglycemics do not directly cause decreased circulation; this is more commonly related to underlying vascular disease, not medication side effects.
Correct Answer is D
Explanation
A. Diabetic nephropathy is a long-term complication and not part of initial "survival skills" education.
B. While DKA is a serious condition, its detailed management is beyond the scope of initial teaching.
C. Effects of surgery and pregnancy are advanced topics more appropriate for ongoing education.
D. Recognition of hypoglycemia and hyperglycemia is a critical survival skill for newly diagnosed clients with type 1 diabetes. Early recognition and appropriate response can prevent life-threatening complications.
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