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?
Infiltration
Extravasation
Venous spasm
Phlebitis
The Correct Answer is D
A. Infiltration:
Infiltration refers to the inadvertent administration of a non-vesicant solution into the surrounding tissue. It is characterized by swelling, pallor, and coolness at the infusion site, but redness and inflammation along the vein are not typical signs of infiltration.
B. Extravasation:
Extravasation occurs when a vesicant solution (a substance that can cause tissue damage) infiltrates into the surrounding tissue. It can cause tissue damage and necrosis. While inflammation is a concern with extravasation, it is not the primary sign, and redness may occur later.
C. Venous spasm:
Venous spasm involves the constriction of the blood vessel, leading to decreased blood flow. It is not typically associated with redness and inflammation along the vein.
D. Phlebitis:
This is the correct answer. Phlebitis refers to inflammation of a vein, and it is characterized by redness, warmth, and tenderness along the course of the vein. Phlebitis can be caused by various factors, including irritants in the infused solution, mechanical trauma, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client's absolute neutrophil count was 2.500/mm before the medication was administered:
This information does not indicate an error in the administration process. The absolute neutrophil count being 2.500/mm before the medication was given is relevant to the client's condition but does not suggest an incident related to the administration of filgrastim.
B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered:
Flushing the IV line with dextrose 5% in water is a standard practice before and after medication administration. This action helps ensure that the medication is effectively delivered and that the line remains patent. There is no indication of an error in this case.
C. The medication vial sat at room temperature for 2 hr before it was administered:
Filgrastim is a medication that typically requires refrigeration to maintain stability. Allowing it to sit at room temperature for an extended period can affect its efficacy and safety. This is a deviation from the recommended storage conditions and should be reported as an incident to assess potential consequences.
D. The client had chemotherapy 12 hr before the medication was administered:
This information does not necessarily suggest an incident related to the administration of filgrastim. The timing of chemotherapy is an essential consideration in cancer treatment protocols. Filgrastim is often administered to support recovery from the hematopoietic effects of chemotherapy.
Correct Answer is D
Explanation
A. Oxygen saturation 96%:
Oxygen saturation at 96% is within the normal range and may not be directly influenced by the infusion of albumin. Albumin administration is more related to improving intravascular volume and blood pressure.
B. PaCO2 30 mm Hg:
The partial pressure of carbon dioxide (PaCO2) is a measure of respiratory status. Albumin infusion is not directly associated with changes in PaCO2.
C. Decrease in protein:
Albumin is a protein, and its infusion would not lead to a decrease in protein levels. In fact, albumin administration increases the oncotic pressure in the intravascular space, helping to retain fluid and improve blood volume.
D. Increase in BP:
This is the correct answer. Albumin is a colloid solution that increases oncotic pressure in the bloodstream. By increasing oncotic pressure, albumin helps to draw fluid from the interstitial space into the vascular space, thereby increasing blood volume. This can contribute to an increase in blood pressure, which is a desired effect in the management of shock.
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