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. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
Correct Answer is B
Explanation
The correct answer is choice b. Performing indwelling urinary catheter care.
Choice A rationale:
Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).
Choice B rationale:
Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.
Choice C rationale:
Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.
Choice D rationale:
Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.
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