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 B
Explanation
The correct answer is Choice B.
Choice A rationale: Advanced beginners are newly graduated nurses who rely on limited experience and follow guidelines strictly. They cannot yet mentor others effectively because they lack the necessary comprehensive knowledge and practical skills for precepting new staff members.
Choice B rationale: Proficient nurses have a deep understanding of clinical situations through experience. They can recognize patterns, predict outcomes, and provide effective mentorship as preceptors. They are skilled at guiding new staff members and improving their clinical performance.
Choice C rationale: Expert nurses possess an intuitive grasp of clinical situations and make decisions rapidly. While they are highly skilled, the role of preceptor is generally better suited to proficient nurses who are adept at breaking down complex tasks for new learners.
Choice D rationale: Competent nurses have a few years of practice and can plan and manage patient care efficiently. However, they are not yet at the stage where they can fluidly adapt to varying situations or mentor new staff as effectively as proficient nurses.
Correct Answer is D
Explanation
Choice A rationale:
Standards of care for monitoring clients with a history of blood pressure elevation are important, but they are not the best resource for health promotion activities for clients with hypertension. This choice is more focused on monitoring and care standards.
Choice B rationale:
A critical pathway for clients who have had a stroke is specific to a different condition and not related to health promotion for clients with hypertension. It does not provide the information needed for the presentation.
Choice C rationale:
Acute care facility protocol for clients experiencing a hypertensive crisis is important for managing emergencies, but it is not the best resource for health promotion activities. It deals with crisis management rather than prevention.
Choice D rationale:
Clinical practice guidelines for the management of high blood pressure are the most appropriate resource for the nurse's presentation on health promotion activities for clients with hypertension. These guidelines provide evidence-based recommendations for managing and preventing high blood pressure, making them the best choice for the presentation. .
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