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:
Abstract thinking develops during the formal operational stage of Piaget's cognitive development theory. This stage typically occurs in adolescence and beyond. During this stage, individuals can think abstractly, solve complex problems, and reason about hypothetical situations. They can also engage in deductive reasoning, which allows them to think logically and systematically.
Choice B rationale:
The concrete operational stage in Piaget's theory, not the formal operational stage, is characterized by the development of logical thinking and operational thought. It typically occurs in children aged 7 to 11 and is marked by the ability to think logically about concrete events and objects.
Choice C rationale:
The sensorimotor stage is the earliest stage in Piaget's theory, occurring in infants from birth to about 2 years old. This stage is characterized by sensory and motor exploration of the environment, and abstract thinking has not yet developed at this stage.
Choice D rationale:
The preoperational stage in Piaget's theory, which typically occurs in children aged 2 to 7, is marked by the development of symbolic thought and language. However, abstract thinking is not a characteristic of this stage.
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