A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?
Thrombophlebitis
Infiltration
Infection
Extravasation
The Correct Answer is A
Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.
Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.
Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.
Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Encouraging coughing and deep breathing is important for postoperative care to prevent complications such as atelectasis and pneumonia. However, with an oxygen saturation of 85%, the immediate priority is to address the client’s hypoxemia. Once oxygen levels are stabilized, coughing and deep breathing exercises can be encouraged.
Choice B reason: Elevating the client to a high Fowler’s position can help improve lung expansion and ease breathing. While this is a beneficial intervention, it is not the first priority when the client’s oxygen saturation is critically low. Administering oxygen should be the initial step to quickly improve oxygenation.
Choice C reason: Administering prescribed analgesic medication is essential for managing the client’s pain, which can also help improve breathing patterns. However, pain management should follow the immediate correction of hypoxemia. Ensuring adequate oxygenation takes precedence over pain relief in this scenario.
Choice D reason: Administering oxygen at 2 L/min is the first action the nurse should take. With an oxygen saturation of 85%, the client is experiencing significant hypoxemia, which needs to be corrected promptly to prevent further complications. Oxygen therapy will help increase the oxygen levels in the blood and improve the client’s overall condition.
Correct Answer is C
Explanation
Advance directives are legal documents that allow individuals to outline their preferences for medical treatment in case they become unable to communicate their decisions. These documents typically include a living will and a durable power of attorney for healthcare. The living will specifies the types of medical treatment a person wishes to receive or avoid, while the durable power of attorney for healthcare designates a trusted individual to make healthcare decisions on their behalf.
Choice A Reason:
“I will get my regular doctor to approve my plan before I hand it in to the hospital.”
This statement indicates a misunderstanding of the purpose of advance directives. While it is important to discuss your advance directives with your healthcare provider, the primary purpose of these documents is to communicate your wishes regarding medical treatment, not to seek approval from your doctor. The advance directive is a personal document that reflects your values and preferences for medical care.
Choice B Reason:
“I know they won’t go ahead with the surgery unless I prepare these forms.”
This statement also reflects a misunderstanding. While having advance directives in place is highly recommended, it is not typically a prerequisite for undergoing surgery. Advance directives are important for ensuring that your medical wishes are respected, but they are not mandatory for surgical procedures. The focus should be on making sure your wishes are known and documented, rather than on the necessity of the forms for surgery.
Choice C Reason:
“I plan to write that I do not want them to keep me on a breathing machine.”
This statement correctly reflects the purpose of an advance directive. It shows that the patient understands that they can specify their preferences for medical treatment, such as whether or not they want to be kept on a breathing machine. This type of instruction is a common component of a living will, which is part of an advance directive. It ensures that healthcare providers are aware of the patient’s wishes regarding life-sustaining treatments.
Choice D Reason:
“I would rather have my brother make decisions for me, but I know he has to be my wife.”
This statement is incorrect and confusing. It seems to mix up the roles of different individuals. In an advance directive, you can designate a healthcare proxy or durable power of attorney for healthcare, who can be any trusted person, not necessarily a spouse. The statement also contains a factual error, as it implies that the brother must be the patient’s wife, which is not possible. The correct understanding is that you can choose any trusted individual to make healthcare decisions on your behalf.
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