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, B, C, D, E
Explanation
Correct Answer is A
Explanation
Choice A Reason:
Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.
Choice B Reason:
Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.
Choice C Reason:
Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.
D. Absent bowel sounds
Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.
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