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 B
Explanation
When a client is receiving gentamicin via IV infusion, it's essential to monitor for potential adverse effects. One of the well-known adverse effects of gentamicin is ototoxicity, which can manifest as hearing loss. Therefore, the nurse should identify the following manifestation as an adverse effect of the treatment:
B) New onset of hearing loss
Hypotension (option A), hyperthermia (option C), and slurred speech (option D) are not typically associated with gentamicin use and would be less likely to be related to the treatment. However, it's essential to assess the client for other side effects and monitor their overall condition while receiving gentamicin to ensure their safety and well-being.
Correct Answer is C
Explanation
The correct answer is C. "Fidelity involves keeping promises made to clients." The rationale for this statement is that fidelity is a principle of ethics that requires nurses to be faithful, loyal, and trustworthy to their clients. Fidelity means that nurses should honor their commitments and obligations to their clients, such as following through with care plans, respecting confidentiality, and being honest. Fidelity also implies that nurses should advocate for their client's best interests and protect them from harm.
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