A nurse is caring for a client who is receiving intravenous fluids. The nurse notes the client's skin around their peripheral IV site is taut and edematous. Which of the following complications is the client experiencing?
Infection
Infiltration
Air embolism
Phlebitis
The Correct Answer is B
A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.
B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.
C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.
D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Would you like to discuss other treatment options with your provider?": This response invites the client to express concerns and explore alternative treatments. It shows respect for their preferences and promotes a collaborative decision-making process.
B. "Regular monitoring is not difficult and will ensure that you remain healthy.": This response downplays the client’s concerns and could be seen as dismissive. It focuses more on the ease of monitoring than addressing the client’s discomfort.
C. "Your provider wants you to take this medication.": Using authority to justify medication may cause the client to feel coerced rather than involved in their treatment. This doesn’t address their concerns and may erode trust.
D. "Why don't you want to undergo monitoring?": Asking why could put the client on the defensive and may make them feel judged. It doesn’t foster open communication or understanding of the client’s concerns.
Correct Answer is B
Explanation
A. Leave resuscitation equipment and supplies at the bedside: This can be distressing for the family. Removing such equipment before the family views the body promotes a more peaceful environment.
B. Hold the client's eyelids closed until they remain shut: This is part of postmortem care to maintain a natural appearance. It shows respect and helps prepare the body before the family views it.
C. Apply identification tags to the client's extremities: While necessary, identification tagging is not a priority before the family views the body. It is typically done before transport to the morgue.
D. Keep the head of the bed flat: Elevating the head of the bed slightly helps prevent discoloration due to blood pooling and gives the body a more natural appearance. Keeping it flat is not ideal.
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