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 D
Explanation
Choice A Reason:
Discard the medication if it is yellow is incorrect. While amphotericin B lipid complex can have a yellowish color, it's important to follow specific guidelines provided by the manufacturer or pharmacy regarding any discoloration or changes in the medication's appearance. Discoloration could indicate degradation or contamination, and it's crucial to adhere to specific institutional policies in such cases.
Choice B Reason:
Administer the medication over 2 hr is incorrect. Amphotericin B lipid complex is usually given over a longer duration (e.g., several hours) due to the potential for infusion-related reactions. Intermittent IV bolus administration over 2 hours might not be appropriate and can increase the risk of adverse reactions.
Choice C Reason:
Use a gravity flow set is incorrect. For medications like amphotericin B lipid complex, which often require precise infusion rates and careful monitoring, using an IV infusion pump is usually recommended instead of a gravity flow set. An infusion pump allows for more accurate control of the infusion rate and reduces the risk of errors.
Choice D Reason:
Prime the tubing with 0.9% sodium chloride is correct. Amphotericin B lipid complex should be administered according to specific instructions and precautions. Priming the IV tubing with 0.9% sodium chloride helps ensure that the medication is effectively delivered to the patient and that the medication is not affected by remnants of previous IV solutions in the tubing.
Correct Answer is B
Explanation
Choice A Reason:
Weight loss is incorrect. While weight loss can be a side effect of citalopram, it's not typically considered a severe or urgent adverse effect that requires immediate reporting to the provider. It's more often observed in some individuals as a common side effect of this medication.
Choice B Reason:
Confusion can indicate a severe or uncommon adverse reaction to citalopram, especially in the context of treating major depression. It could potentially signify a serious condition that requires immediate attention. Reporting confusion promptly allows the healthcare provider to assess the situation and make appropriate adjustments to the medication regimen or provide additional interventions if necessary.
Choice C Reason:
Insomnia is incorrect. Insomnia is another potential side effect of citalopram. While it can affect the individual's quality of life, it's not typically an adverse effect that would be considered an urgent concern requiring immediate reporting to the provider.
Choice D Reason:
Bruxism is incorrect. Bruxism, or teeth grinding, is a less common side effect of citalopram. While it can cause discomfort or dental issues, it's not typically considered a priority adverse effect that necessitates immediate reporting to the provider compared to confusion, which might indicate a more serious or severe reaction.
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