After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?
Infiltration
Phlebitis
Extravasation
Infection
- E. Limited ambulation
The Correct Answer is B
A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Serum potassium 3.2 mEq/L: A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac arrhythmias and muscle weakness. This condition requires prompt correction and collaboration with the healthcare provider before surgery to avoid intraoperative and postoperative complications.
B. Pulse rate 65 bpm: A pulse rate of 65 bpm is within the normal range (60-100 bpm). While it should be monitored, it does not require immediate intervention or collaboration with the healthcare provider before surgery.
C. Hematocrit 36%: A hematocrit level of 36% is within the lower end of the normal range (35-45% for women). This does not indicate an immediate concern that requires prompt collaboration with the healthcare provider.
D. Blood pressure 144/82 mmHg: Although this blood pressure reading is slightly elevated, it is not uncommon and can be managed perioperatively. It does not require immediate intervention before surgery.
Correct Answer is D
Explanation
A. Dry oral mucus membranes: This finding indicates dehydration rather than improvement. Effective treatment would result in the rehydration of mucous membranes.
B. Weight loss: Weight loss can be a sign of ongoing dehydration or fluid loss. Effective treatment would be indicated by weight stabilization or gain, not loss.
C. Jugular vein distention: Jugular vein distention typically indicates fluid overload or poor cardiac function, not improvement in dehydration. Effective rehydration would be associated with a return to normal vein appearance.
D. Daily urine output of 960 mL: This is the correct choice as it reflects adequate fluid intake and kidney function. For an average adult, a daily urine output of around 960 mL suggests proper hydration, indicating that interventions have been effective.
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