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 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.
Correct Answer is B
Explanation
The correct answer is B. Placement of a central venous catheter.
Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits.
Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.
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