A nurse is caring for a client who is receiving intravenous therapy and observes redness and inflammation along the vein. The nurse should identify this finding as which of the following complications of IV therapy?
Extravasation
Phlebitis
Infiltration
Venous spasm
The Correct Answer is B
Choice A Reason:
Extravasation is incorrect. This occurs when the intravenous fluid leaks into the surrounding tissue rather than remaining within the vein. It may cause swelling, pain, and potential tissue damage due to the infused solution's irritant effects.
Choice B Reason:
Phlebitis is correct. Phlebitis refers to the inflammation of a vein often characterized by redness, warmth, swelling, and tenderness along the course of the vein. It can occur due to various reasons, including irritation from the IV catheter, chemical irritation from the infused solution, or infection.
Choice C Reason:
Infiltration is incorrect. Infiltration refers to the inadvertent leakage of the infused fluid into the surrounding tissues. It may cause swelling and discomfort but doesn't typically present with redness and inflammation along the vein.
Choice D Reason:
Venous spasm is incorrect. Venous spasm involves the involuntary contraction of the vein, which can occur in response to irritation or trauma. It may cause temporary difficulty in IV access but does not usually present with redness and inflammation along the vein as the primary signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is D
Explanation
Choice A Reason:
Hct 44% is incorrect. A hematocrit (Hct) level of 44% falls within the normal range for most adults. It represents the proportion of red blood cells in the blood and is not typically concerning unless it significantly deviates from the normal range, indicating anemia or polycythemia.
Choice B Reason:
WBC count 5,000/mm3 is incorrect. A white blood cell (WBC) count of 5,000/mm3 falls within the normal range for adults, reflecting a normal immune response. There's usually no cause for immediate concern unless there are specific clinical symptoms or significant deviations from the normal range.
Choice C Reason:
Potassium 4.2 mEq/L is incorrect. A potassium level of 4.2 mEq/L is within the normal range for serum potassium levels. It's crucial to monitor potassium levels, especially with medications that can affect electrolyte balance, but this value falls within the typical range and may not prompt immediate action unless there are notable fluctuations or clinical symptoms related to potassium imbalance.
While the majority of the laboratory values provided fall within the normal range, the value that the nurse should consider reporting to the provider, particularly when a client is taking amitriptyline, is:
Choice D Reason:
Total bilirubin 1.5 mg/dL is correct. Elevated levels of total bilirubin might indicate potential liver function impairment. Amitriptyline, an antidepressant, can affect liver enzymes in some individuals, causing hepatic changes. Therefore, it's crucial to monitor liver function tests, including total bilirubin, during amitriptyline therapy. An increase in bilirubin levels could signal hepatotoxicity or liver dysfunction related to the medication.
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