During a clinical rotation on an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool, blanched and slightly swollen. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?
Infiltration
Local inflammation
Thrombophlebitis
Phlebitis
The Correct Answer is A
A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.
B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.
C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.
D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Recapping needles increases the risk of needlestick injuries. Needles used for arterial blood gas (ABG) specimens should never be recapped because this action significantly increases the likelihood of accidental puncture wounds.
B. Recapping needles can lead to accidental needlesticks, so it's safer to avoid this practice. Instead, needles should be immediately disposed of in a puncture-proof sharps container.
CA Recapping needles is strongly discouraged because it increases the risk of needlestick injuries. Placing needles in a regular wastebasket does not provide adequate protection from needlestick injuries and is not in line with safe disposal practices.
D. Breaking needles is hazardous and increases the risk of needlestick injuries. Needles should never be manipulated or broken before disposal. They should be placed intact in a sharps disposal container to prevent accidental exposure.
Correct Answer is D
Explanation
D Excessive use of bisacodyl or other laxatives can indeed cause these adverse effects. Rectal burning can occur due to irritation from frequent bowel movements, while dehydration and electrolyte imbalance can result from fluid loss caused by frequent laxative use.
A. While regular bowel movements are important for many individuals, daily bowel movements are not necessary for everyone and can vary depending on diet, hydration, and individual health conditions.
B. Bisacodyl is a stimulant laxative used for short-term relief of constipation. It does not interact with dietary fiber intake, nor should the client necessarily decrease high-fiber foods unless specifically advised by their healthcare provider for other reasons.
C. Chronic use of bisacodyl, a stimulant laxative, can indeed lead to dependence and potentially harmful effects on the body's water and salt balance
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.