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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I will have my partner tilt their head back while I am instilling the drops:"
Tilting the head back is not the recommended position for administering otic (ear) drops. This position can lead to the medication running out of the ear rather than staying in the ear canal.
B. "I will have my partner lie down on their back while I am instilling the drops:"
While lying down is a better position than tilting the head back, it is not as effective as the correct technique of pulling the pinna upward and outward. Lying down may still allow the drops to flow out of the ear.
C. "I will pull the pinna upward and outward prior to instilling the drops:"
This is the correct answer. The proper technique for administering otic drops involves pulling the pinna (outer ear) upward and outward. This straightens the ear canal, facilitating the correct placement of the medication.
D. "I will make sure the solution is cool prior to instilling the drops:"
The temperature of the solution is not typically a specific consideration for ear drops unless otherwise specified by the healthcare provider. Room temperature drops are generally acceptable.

A. Thready pulse B. Decreased bowel sounds C. Bilateral muscle weakness D. Distended neck veins

Correct Answer is D

Explanation

A. Thready pulse:
A thready pulse is more indicative of fluid volume deficit or inadequate cardiac output, not fluid volume excess.
B. Decreased bowel sounds:
Decreased bowel sounds are not a specific sign of fluid volume excess. They may be associated with various gastrointestinal issues but are not directly related to fluid volume status.
C. Bilateral muscle weakness:
Bilateral muscle weakness is not a specific manifestation of fluid volume excess. It may be associated with electrolyte imbalances or other neuromuscular issues.
D. Distended neck veins:
This is the correct answer. Distended neck veins are a classic sign of fluid volume excess or overload. Increased venous pressure from excess fluid can lead to distension of the jugular veins in the neck. This finding is often seen in conditions such as heart failure or renal failure where there is an inability to adequately excrete or distribute fluids.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client's partner how to administer an otic medication to the client. Which of the following statements by the client's partner indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Correct Answer is D

Explanation

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