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. Stroke volume: While stroke volume is an important parameter in assessing cardiac function, it may not directly guide the titration of nitroprusside infusion. Blood pressure is a more immediate indicator of the drug's effect on vasodilation.
B. Urine output: Nitroprusside primarily affects the vascular system and is not directly associated with urine output. Monitoring urine output is crucial in assessing renal function, but it is not the primary parameter for titrating a nitroprusside infusion.
C. Blood pressure (Correct Answer): Nitroprusside acts as a direct vasodilator, and its primary effect is on blood vessels, leading to a reduction in blood pressure. Therefore, monitoring blood pressure is essential to titrate the infusion to achieve the desired therapeutic effect.
D. Cardiac output: While nitroprusside's vasodilatory effect may influence cardiac output indirectly, blood pressure is a more immediate and specific parameter to guide the titration of the infusion. Nitroprusside is often titrated to reach a target blood pressure range in hypertensive emergencies.
Correct Answer is C
Explanation
A. INR (International Normalized Ratio): INR is a measure of blood clotting and is not directly affected by filgrastim, which stimulates the production of white blood cells. Monitoring INR is more relevant when assessing anticoagulant therapy.
B. Potassium level: Filgrastim does not directly influence potassium levels. Monitoring potassium is important for certain medications and conditions, but it is not the primary parameter to evaluate the effectiveness of filgrastim.
C. WBC count: Filgrastim (granulocyte colony-stimulating factor) is used to stimulate the production of white blood cells, specifically neutrophils. Monitoring the white blood cell count is crucial in evaluating the effectiveness of filgrastim treatment. An increase in the WBC count, particularly the neutrophil count, indicates a positive response to the medication.
D. BUN (Blood Urea Nitrogen): BUN is a measure of kidney function and is not directly influenced by filgrastim. While monitoring kidney function is important in general patient care, it is not the primary parameter to assess the effectiveness of filgrastim.
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