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
Answer and explanation
The correct answer is choice B.
Choice A rationale:
Yoga involves gentle stretching and may not directly impact the phlebitis.
Choice B rationale:
Therapeutic massage could potentially dislodge a clot in the leg, leading to a dangerous condition called a pulmonary embolism.
Choice C rationale:
Acupressure, like yoga, involves gentle pressure and may not directly impact the phlebitis.
Choice D rationale:
Acupuncture involves the insertion of needles and could potentially cause harm, but it is less likely to dislodge a clot than massage.
Correct Answer is A
Explanation
Choice A rationale:
Skilled nursing is the most appropriate resource to anticipate for a postoperative client who needs physical therapy 2-3 times per day for two weeks. Skilled nursing facilities provide care from licensed nurses and therapists, making them well-suited for short-term rehabilitation and therapy services. These facilities offer a higher level of medical care compared to the other options, ensuring that the client's postoperative needs are adequately met.
Choice B rationale:
Assisted living is not the most suitable option for a postoperative client who requires physical therapy multiple times a day. Assisted living facilities are generally designed for individuals who need assistance with daily activities but do not require constant medical or therapeutic interventions.
Choice C rationale:
Long-term care is not the appropriate choice for a postoperative client with a two-week prescription for physical therapy. Long-term care facilities are designed for individuals who require ongoing, extended care, often due to chronic illnesses or disabilities. The client's condition is temporary, so long-term care is not warranted.
Choice D rationale:
Palliative care is intended for clients with serious, life-limiting illnesses, focusing on pain management and improving the quality of life. It is not suitable for a postoperative client who needs physical therapy for a limited duration. The primary goal of palliative care is different from the client's needs in this scenario.
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