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:
Using a fire extinguisher at the source of the smoke is not appropriate. While using a fire extinguisher could potentially help contain a small fire, it's crucial to prioritize rescuing those in immediate danger and alerting others about the fire first by activating the fire alarm. This action ensures that help is on the way and that everyone is aware of the emergency.
Choice B Reason:
Closing the doors to the room and to the bathroom is not appropriate. Closing doors can help contain smoke and fire to some extent, but again, the priority in an emergency situation like this is to rescue those in immediate danger then activate the fire alarm to ensure a swift response and alert others.
Choice C Reason:
Activate the fire alarm system is appropriate. Activating the fire alarm alerts others in the facility and initiates the emergency response protocol, helping to ensure that help is on the way while potentially preventing the spread of fire. However, this step should be taken after assisting the client to safety as they are in immediate danger.
Choice D Reason:
Assisting the client who is in immediate danger to a nearby common area should be the furst step that the nurse takes before alerting other people of the fire. (RACE protocol)
Correct Answer is D
Explanation
Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.
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