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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.
Choice B Reason:
Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.
Choice C Reason:
Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.
Choice D Reason:
Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.
Correct Answer is C
Explanation
Choice A Reason:
Asking “When did you begin to have trouble sleeping?” is important for understanding the onset and duration of the client’s insomnia. However, it does not directly address immediate safety concerns. Chronic insomnia can lead to significant daytime impairment, but the question about the onset of sleep troubles does not identify specific safety risks.
Choice B Reason:
Inquiring about specific factors affecting the client’s ability to sleep can help identify potential causes of insomnia, such as stress, environmental factors, or medical conditions. While this information is valuable for treatment planning, it does not directly address immediate safety concerns.
Choice C Reason:
Asking “Do you have difficulty staying awake when you are driving?” addresses the highest safety priority. Chronic insomnia can lead to excessive daytime sleepiness, which significantly increases the risk of accidents, especially while driving. Identifying whether the client is at risk of falling asleep during potentially dangerous activities is crucial for immediate safety.
Choice D Reason:
Understanding the client’s bedtime routine can provide insights into their sleep hygiene and habits, which are important for managing insomnia. However, this question does not directly address immediate safety concerns related to daytime functioning and the risk of accidents.
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