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 A
Explanation
A. Assess the client for adverse reactions:
After ensuring the client's safety and well-being, the nurse can then proceed with the other necessary actions, such as determining the factors that led to the omission, filing an incident report, and reporting the missed dosage to the client's provider. However, assessing the client for any immediate adverse reactions takes precedence to address any potential harm that may have resulted from the missed medication dose.
B. Determine factors that led to the omission:
This is the correct answer. Understanding the factors that led to the omission is crucial for preventing future errors. The nurse should assess if there were any system failures, distractions, or other factors contributing to the missed dose.However, patient's safety and wellbeing comes first.
C. File an Incident report:
Filing an incident report is an important step, but it should not be the first action. The nurse needs to address the immediate situation and assess the factors contributing to the omission first.
D. Report the missed dosage to the client's provider:
Reporting the missed dosage to the provider is an important step, but it should not be the first action. The nurse needs to address the immediate situation, assess the client, and determine factors leading to the omission before reporting to the provider.
Correct Answer is B
Explanation
A. "You will need to undergo tuberculin skin tests every 6 months while taking medication for your disease."
Tuberculin skin tests are typically used for screening and diagnosis, not for monitoring the effectiveness of tuberculosis treatment. Monitoring for treatment effectiveness involves assessing symptoms, sputum cultures, and other diagnostic tests.
B. "You will need to take two or more medications to treat your disease."
This is the correct answer. Tuberculosis is usually treated with a combination of antibiotics to prevent the development of drug resistance. Multidrug therapy is a standard approach to tuberculosis treatment.
C. "You should anticipate taking medication to treat your disease for at least the next 3 years."
The duration of tuberculosis treatment is generally shorter than 3 years. The standard treatment duration is typically 6 to 9 months, depending on the specific regimen used.
D. "You should report monthly to have your blood drawn to monitor kidney function while taking medication."
Monitoring kidney function is important for some medications, but it is not a standard monthly requirement for tuberculosis treatment. Monitoring typically involves assessing liver function, as certain tuberculosis medications can affect the liver.
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