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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.

A. Loperamide should not be used if diarrhea is infectious. B. You can take loperamide until the diarrhea stops. C. Loperamide has no side effects. D. Loperamide should not stop this type of diarrhea.

Correct Answer is A

Explanation

Choice A Reason:

Loperamide should not be used if diarrhea is infectious is correct. Loperamide is an antidiarrheal medication that works by slowing down gut movement. However, if the diarrhea is caused by an infection, such as from spoiled food, it is important to allow the body to expel the infectious agents. Using loperamide in such cases can prolong the infection and potentially worsen the condition.

Choice B Reason:

You can take loperamide until the diarrhea stops is incorrect. While loperamide can be effective for non-infectious diarrhea, it is not recommended for infectious diarrhea. Stopping the diarrhea prematurely can trap the infectious agents in the intestines, leading to more severe symptoms.

Choice C Reason:

Loperamide has no side effects is incorrect. Loperamide can have side effects, including constipation, dizziness, and abdominal pain. It is important to use this medication under the guidance of a healthcare provider, especially in cases of infectious diarrhea.

Choice D Reason:

Loperamide should not stop this type of diarrhea is incorrect. While it is true that loperamide should not be used for infectious diarrhea, the statement is misleading. Loperamide can stop diarrhea, but it is not appropriate for all types of diarrhea, particularly those caused by infections.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

Correct Answer is C

Explanation

A nurse is caring for a client with numerous episodes of watery diarrhea. The client reports eating some spoiled deli meat earlier in the day. The client asks if they should take loperamide (Imodium) to stop the diarrhea. What would be an appropriate response from the nurse?

Correct Answer is A

Explanation

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