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 B
Explanation
A. Bradycardia:
Bradycardia is not a typical manifestation of an allergic reaction. Allergic reactions are more likely to involve symptoms such as rash, itching, swelling, and cardiovascular symptoms like tachycardia rather than bradycardia.
B. Hypotension:
This is the correct answer. Hypotension (low blood pressure) can be a sign of an allergic reaction, particularly in severe cases. Anaphylaxis, a severe allergic reaction, can lead to a rapid drop in blood pressure.
C. Polyuria:
Polyuria, excessive urine production, is not a typical manifestation of an allergic reaction. Allergic reactions are more likely to involve skin, respiratory, and cardiovascular symptoms.
D. Nausea:
Nausea can be a side effect of medications, but it is not a specific manifestation of an allergic reaction. Allergic reactions are more likely to present with symptoms such as skin rash, itching, or respiratory distress.
Correct Answer is B
Explanation
A. "You should take this medication on an empty stomach:"
Bumetanide can be taken with or without food. It is not necessary to take it on an empty stomach.
B. "You should monitor for hearing difficulties:"
This is the correct answer. Loop diuretics, including bumetanide, are associated with ototoxicity, which can lead to hearing difficulties or hearing loss. Clients should be instructed to report any changes in hearing.
C. "You should decrease your intake of foods high in potassium:"
Bumetanide can cause potassium loss, but instructing the client to decrease potassium intake may not be appropriate without knowing the client's specific potassium levels. Monitoring potassium levels and adjusting the diet or prescribing supplements as needed would be a more individualized approach.
D. "You should take the medication at bedtime:"
Bumetanide is often prescribed in the morning to avoid disrupting sleep with increased urination during the night. Taking it at bedtime is not a typical recommendation.
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