A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
Nerve damage
Infection
Infiltration
Phlebitis
The Correct Answer is C
Choice A Reason:
Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.
Choice B Reason:
Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.
Choice C Reason:
Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.
Choice D Reason:
Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.
Choice B Reason:
The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.
Choice C Reason:
The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.
Choice D Reason:
The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.
Correct Answer is A
Explanation
Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming effects and can help reduce agitation and anxiety. However, the use of any medication should be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially escalate the situation or increase the risk of falls or injury. Safety should be a priority, and ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of confusion, fear, or distress, potentially worsening the agitation. It's important to engage and support the client rather than isolate them, which can be distressing for someone with Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only be considered as a last resort when all other measures have failed and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful, leading to increased agitation, anxiety, and potential injury. They should be used only under strict guidelines and with proper authorization when all other interventions have been exhausted.
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