A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

Infiltration

Extravasation

Circulatory overload

Phlebitis

Answer and Explanation

The Correct Answer is D

Choice A reason:

Infiltration is not correct: Infiltration occurs when the infused fluid or medication leaks into the surrounding tissue instead of flowing into the vein. This can lead to swelling, coolness, and pallor around the insertion site.

Choice B reason:

Extravasation is not correct: Extravasation is similar to infiltration but specifically refers to the infiltration of vesicant medications, which can cause tissue damage and necrosis.

Choice C reason:

Circulatory overload is not correct: Circulatory overload occurs when a large volume of fluid is infused too quickly, overloading the circulatory system and potentially leading to fluid overload, pulmonary edema, and other related symptoms.

Choice D reason:

Phlebitis is the appropriate fingings. The nurse should document the finding of redness and warmth around the peripheral catheter insertion site as phlebitis. Phlebitis is the inflammation of a vein, often caused by mechanical irritation, chemical irritation, or infection. In this case, the redness and warmth at the insertion site are indicative of inflammation, which is a common sign of phlebitis.

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Correct Answer is A

Explanation

The correct answer is A. A client who has a spinal cord injury requires an interprofessional approach to care that involves multiple disciplines such as physical therapy, occupational therapy, social work, and rehabilitation nursing. The other clients have less complex needs that can be managed by one or two disciplines.

A. I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water. B. I will place used sharp items in an empty cereal box for disposal. C. I will put soiled dressings in a tied plastic bag before placing them in the trash. D. I will use animal-skin condoms when having sex.

Correct Answer is C

Explanation

The correct answer is C. Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.

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A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

Nursing Test Bank

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