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 C
Explanation
Choice A reason: Cover
Covering a wound with slough is not an appropriate intervention. Slough is a type of necrotic tissue that can impede the healing process by providing a medium for bacterial growth and preventing the formation of healthy granulation tissue. Simply covering the wound without addressing the slough can lead to infection and delayed healing.
Choice B reason: Clean
Cleaning the wound is a necessary step in wound care, but it is not sufficient on its own to address the presence of slough. While cleaning can help reduce the bacterial load and remove some debris, it does not effectively remove the slough itself. Slough often requires more targeted interventions such as debridement to be effectively managed.
Choice C reason: Debride
Debridement is the most appropriate intervention for a wound with slough. Debridement involves the removal of necrotic tissue, including slough, to promote a clean wound bed and facilitate the healing process. There are several methods of debridement, including autolytic, enzymatic, mechanical, and surgical, each with its own indications and benefits. Removing the slough allows for better assessment of the wound and promotes the formation of healthy granulation tissue.
Choice D reason: Leave Alone
Leaving a wound with slough alone is not advisable. Slough can harbor bacteria and impede the healing process, leading to chronic wounds and potential infection. Without intervention, the wound is unlikely to progress through the normal stages of healing.
Correct Answer is A
Explanation
Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.
Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.
Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.
Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.
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