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
A. 0.9% sodium chloride (normal saline) is isotonic, meaning it has the same concentration of solutes as blood plasma. It is used to expand intravascular volume and replace fluids and electrolytes.
B. "Hypnotic" refers to medications that induce sleep and has no relevance to IV solutions. This term does not apply to IV solutions.
C. A hypotonic solution has a lower concentration of solutes compared to normal body fluids. Examples include 0.45% sodium chloride (half-normal saline) or 5% dextrose in water (D5W). 0.9% sodium chloride (normal saline) is not hypotonic; rather, it is isotonic.
D. A hypertonic solution has a higher concentration of solutes compared to normal body fluids. Examples include 3% sodium chloride or 5% dextrose in 0.9% sodium chloride. 0.9% sodium chloride (normal saline) is not hypertonic; rather, it is isotonic.
Correct Answer is ["A","D"]
Explanation
A. Diarrhea is a common side effect associated with ondansetron, which is used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery.
B. Ondansetron can potentially cause changes in glucose metabolism, leading to hyperglycemia, especially in clients with diabetes mellitus. Monitoring blood glucose levels is essential during ondansetron administration, particularly in clients who are already predisposed to hyperglycemia.
D. Headache is a potential adverse effect of ondansetron. It is listed as a common side effect and should be monitored, especially in older adults who may be more sensitive to medication effects.
C. Ondansetron can affect the QT interval rather than the PR interval. It may cause QT interval prolongation, which can predispose the client to arrhythmias
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