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 D
Explanation
Choice A Reason:
"Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." This statement is incorrect. Generally, having a total cholesterol level below 200 mg/dl is considered beneficial for heart health and reducing the risk of stroke.
Choice B Reason:
"My risk for a stroke increases if my HbA1c level is 6 percent or less." This statement is incorrect. An HbA1c level of 6 percent or less is an indicator of good blood sugar control, which usually reduces the risk of stroke. A higher HbA1c level is associated with an increased risk of complications in diabetes, including stroke.
Choice C Reason:
"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." - Glucocorticoids are not typically prescribed to reduce the risk of stroke in individuals with diabetes. These medications may have various uses but are not a standard preventive measure for stroke in this context.
Choice D Reason:
"I can decrease my risk for a stroke by losing excess weight." This statement is appropriate. Maintaining a healthy weight is a significant factor in reducing the risk of stroke, especially for individuals with diabetes. Weight management contributes to better control of blood pressure, cholesterol levels, and blood sugar, which collectively reduce the risk of stroke.
Correct Answer is A
Explanation
Choice A Reason:
Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45 degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs. This position should ideally be maintained for about 1 hour after the feeding to aid digestion and reduce the risk of complications.
Choice B Reason:
Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions are generally administered at room temperature or slightly warmed to prevent discomfort and minimize the risk of altering the client's core body temperature. Cold temperatures can cause discomfort or cramping and might affect the absorption of the nutrients. Therefore, administering the feeding solution at a cold temperature is not recommended.
Choice C Reason:
Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube is not typically part of routine care. Tube rotation can cause discomfort, irritation, and potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent movement but not rotated unless specifically instructed by a healthcare provider for a particular reason, such as checking for proper tube placement.
Choice D Reason:
Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.
Flushing the tube with sterile water before and after the feeding helps ensure the patency of the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its function
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