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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Clean the stoma using an inward to outward circular motion.
Choice A rationale:
Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.
Choice B rationale:
Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.
Choice C rationale:
Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.
Choice D rationale:
Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.
Correct Answer is A
Explanation
The correct answer is A. The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are
incorrect because they can cause injury or discomfort to the client.
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