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 ["A","B","E","F"]
Explanation
Choice A rationale:
Givingtheclientprintedinformationisaneducationalmethodthatinvolvesreadingandcomprehension,whicharekeycomponentsofthecognitivedomain.
Choice B rationale:
Teaching about expected reference ranges and target blood glucose levels is based on the cognitive domain of learning. This involves understanding and comprehending information, which is a key aspect of cognitive learning. It's important for a client with diabetes to know what their blood glucose levels should be and what values to aim for to manage their condition effectively.
Choice C rationale:
Asking the client how they feel about checking their blood glucose levels is related to the affective domain of learning. It focuses on the client's emotions and attitudes rather than cognitive understanding, which is not directly mentioned in the question.
Choice D rationale:
Asking the client to demonstrate checking their blood glucose level is based on the psychomotor domain of learning. This involves physical skills and actions, which are not explicitly mentioned in the question.
Choice E rationale:
Giving the client a fill-in-the-blank quiz is also based on the cognitive domain of learning. Quizzes and assessments are tools that help assess a client's understanding and retention of information, which aligns with cognitive learning.
Choice F rationale:
Asking the client to describe the manifestations of hypoglycemia and hyperglycemia is also based on the cognitive domain of learning. It requires the client to recall and explain information, which is a cognitive process.
Correct Answer is B
Explanation
Choice A rationale:
Encouraging family members to call the client is a valuable emotional and social support, but it may not be as effective in reducing social isolation for a client at the end of life. While communication with loved ones is important, it may not fully address the client's need for personal interaction.
Choice C rationale:
Instructing the client to join an online support group can be a useful intervention to reduce social isolation, especially in cases where physical interaction is limited. However, it may not be as effective for all clients, as comfort with technology and online groups can vary. Additionally, it should be one of several strategies used to address social isolation.
Choice D rationale:
Asking the client's friends to text the client is a positive gesture, but it may not be as effective as scheduling home visits with the client. Text messages may not provide the same level of personal interaction and emotional support that physical visits can offer.
Choice B rationale:
Scheduling home visits with the client is the most effective intervention to reduce social isolation in a client at the end of life. It allows for in-person interaction, emotional support, and the opportunity to address the client's physical and emotional needs directly. Face-to-face contact can significantly improve the client's sense of connectedness and reduce feelings of isolation.
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