A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking.
The nurse should identify that the client has manifestations of which of the following complications?
Phlebitis.
Infection.
Infiltration.
Circulatory overload.
The Correct Answer is C
Choice A rationale:
Phlebitis is inflammation of a vein, often associated with pain, redness, and warmth at the catheter site. In this case, the client's catheter site is described as cool and taut, which is not consistent with the manifestations of phlebitis.
Choice B rationale:
Infection typically presents with signs such as redness, warmth, swelling, and pain at the catheter site. The description of the client's catheter site as cool and taut is not indicative of infection.
Choice C rationale:
The client's symptoms, including a cool and taut catheter site and IV fluid leaking, are indicative of infiltration. Infiltration occurs when IV fluids inadvertently enter the surrounding tissue instead of the vein. It can lead to localized swelling and discomfort.
Choice D rationale:
Circulatory overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and tachycardia. These symptoms are not consistent with the client's description of a cool and taut catheter site with IV fluid leaking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D: Palliative care can be provided while a client is receiving curative treatment.
Choice A rationale:
The goal of palliative care is not to cure an acute illness but to provide relief from symptoms and improve the quality of life for clients with serious illnesses.
Choice B rationale:
Palliative care is not restricted to clients who are terminally ill. It can be provided to anyone with a serious illness, regardless of the stage of the disease or the need for other therapies.
Choice C rationale:
Palliative care is not limited to clients in a healthcare facility. It can be provided in various settings, including at home, in outpatient clinics, and in long-term care facilities.
Choice D rationale:
Palliative care can be provided alongside curative treatments. It is designed to improve the quality of life for both the patient and the family by addressing physical, emotional, and psychosocial needs.
Correct Answer is ["A","B"]
Explanation
The correct answer is Choice A, Choice B
Choice A rationale: Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that causes antibiotic-associated colitis. Transmission occurs via the fecal-oral route, primarily through contact with contaminated surfaces or hands. Protective gowns are essential during care to prevent spore transfer to clothing and subsequent environmental contamination. Spores resist alcohol-based sanitizers and persist on surfaces for months. Contact precautions, including gown use, reduce nosocomial spread. Normal white blood cell count is 4,000–11,000/mm³; elevated levels may indicate infection severity.
Choice B rationale: Isolation in a private room is critical for clients with confirmed Clostridium difficile infection due to the organism’s ability to form resilient spores that contaminate surfaces and equipment. Private rooms limit environmental exposure and reduce cross-contamination risk. C. difficile spores are resistant to routine cleaning agents and require bleach-based disinfectants. Diarrheal stool volume increases transmission risk. Normal stool frequency is 1–3 formed stools/day; 4–5 liquid stools/day indicates active infectious diarrhea requiring isolation.
Choice C rationale: N-95 respirators are designed for airborne pathogens such as Mycobacterium tuberculosis, measles virus, or varicella-zoster virus. Clostridium difficile is not airborne; it transmits via contact with contaminated surfaces or hands. Spores are shed in feces and do not aerosolize under normal conditions. Therefore, N-95 respirators offer no added protection against CDI. Airborne precautions are unnecessary unless aerosol-generating procedures are performed on patients with concurrent airborne infections. Respiratory rate normal range is 12–20 breaths/min.
Choice D rationale: Negative pressure rooms are used to contain airborne pathogens by maintaining lower air pressure inside the room, preventing contaminated air from escaping. Clostridium difficile does not spread via airborne particles but through contact with contaminated surfaces and feces. Thus, negative pressure rooms are not scientifically justified for CDI. Instead, contact isolation and environmental decontamination are prioritized. Room air exchanges are irrelevant to CDI control. Normal room air pressure is neutral unless airborne precautions are indicated.
Choice E rationale: Masking the client is a droplet precaution used for pathogens like influenza virus, Neisseria meningitidis, or SARS-CoV-2. Clostridium difficile does not transmit via respiratory droplets, so placing a mask on the client during transport does not reduce transmission risk. Instead, hand hygiene and contact precautions are essential. CDI spores are not expelled via coughing or sneezing. Droplet precautions are reserved for pathogens with particle size >5 µm. Normal oxygen saturation is ≥95% on room air.
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