Infiltration and Extravasation

- Infiltration occurs when the IV fluid leaks into the surrounding tissue due to a dislodged or punctured catheter

- Extravasation occurs when a vesicant (a substance that causes tissue damage) infiltrates into the surrounding tissue

- Both infiltration and extravasation can cause pain, swelling, redness, blanching, coolness, or dampness at the IV site

- Extravasation can also cause tissue necrosis, ulceration, or blistering

- The treatment for infiltration and extravasation includes:

- Stopping the infusion and removing the catheter

- Applying cold or warm compresses depending on the type of fluid or medication

- Elevating the affected limb and assessing the circulation

- Aspirating the residual fluid if possible

- Administering antidotes or medications as ordered

- Documenting the incident and notifying the provider

Nursing Test Bank

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Questions on Infiltration and Extravasation

Correct Answer is A

Explanation

This choice is incorrect because air embolism occurs when air enters the vascular system, leading to symptoms such as dyspnea, cyanosis, and chest pain, rather than localized symptoms at the insertion site.

Correct Answer is D

Explanation

This choice is correct. The client's symptoms of sudden chest pain, dyspnea, and tachycardia are potential signs of an air embolism, which occurs when air enters the vascular system through the IV catheter and can lead to serious respiratory and cardiac complications.

Correct Answer is B

Explanation

This choice is incorrect because catheter occlusion may affect the IV flow rate, but it does not typically cause the symptoms described by the client.

Correct Answer is C

Explanation

This choice is incorrect because catheter occlusion does not cause respiratory symptoms like those described by the client.

Correct Answer is A

Explanation

This choice is incorrect because using a large-gauge catheter is not a preventive measure for CRBSIs. The appropriate catheter size should be based on the client's clinical condition and the prescribed therapy.

Correct Answer is C

Explanation

This choice is incorrect because fluid overload is not associated with a painful, warm, and red streak along the arm.Questions

Correct Answer is C

Explanation

This choice is incorrect because the family's request alone is not a sufficient indication for initiating IV therapy. The decision should be based on the client's clinical condition and medical needs.

Correct Answer is C

Explanation

This choice is incorrect because an air embolism is not directly related to the client's history of heart failure.

Correct Answer is D

Explanation

This choice is correct. The client's symptoms of sudden onset dyspnea, chest pain, and cyanosis are indicative of a pulmonary embolism, which occurs when a blood clot travels to the lungs. This can be a life-threatening complication of IV therapy, especially in clients receiving antibiotics who are at higher risk for clot formation.

Correct Answer is C

Explanation

This choice is incorrect because the choice of IV catheter size depends on the medication's compatibility and viscosity, not just using a smaller gauge catheter for all medication infusions.

Correct Answer is D

Explanation

This choice is correct. The client's symptoms of chills, fever, and elevated heart rate are indicative of sepsis, a serious infection that can occur as a complication of IV therapy. Sepsis can develop if bacteria enter the bloodstream through the IV catheter and lead to a systemic inflammatory response.

Correct Answer is D

Explanation

This choice is correct. The client's symptoms of sudden chest pain, difficulty breathing, decreased blood pressure, and weak pulse are indicative of anaphylaxis, a severe allergic reaction. Anaphylaxis can occur in response to an allergen in the IV fluid or medication and can be life-threatening if not treated promptly.

Correct Answer is B

Explanation

This choice is incorrect because IV therapy with a potassium-containing solution is not associated with hyponatremia.Questions

Correct Answer is B

Explanation

This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as swelling and coolness around the IV site.

Correct Answer is D

Explanation

This choice is correct. The nurse should suspect extravasation, which occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture. Burning pain and discomfort at the insertion site are common symptoms of extravasation.

Correct Answer is D

Explanation

This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.

Correct Answer is B

Explanation

This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as edema and coolness around the IV site.

Correct Answer is A

Explanation

This choice is incorrect because administering an analgesic may provide temporary relief, but it does not address the potential complication causing the client's symptoms. The nurse should first stop the IV infusion to assess the site and determine appropriate interventions.Questions

Correct Answer is C

Explanation

This choice is incorrect because an air embolism is not associated with symptoms of phlebitis, such as redness and swelling around the IV site.

Correct Answer is C

Explanation

This choice is incorrect because selecting a small-gauge catheter is not the primary intervention to prevent thrombophlebitis in a client with a history of DVT. The choice of catheter size should be based on the client's clinical needs and vein condition.

This choice is correct. The client's symptoms of chest pain, dyspnea, and tachycardia are potential signs of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can become dislodged and travel to the lungs, leading to a pulmonary embolism, wh

This choice is correct. The client's symptoms of tenderness and a palpable, cord-like structure along the vein are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The palpable cord-like structure is likely a thrombus within the vein.

This choice is incorrect because thrombophlebitis does not typically present with symptoms of fever, chills, and malaise. It is associated with tenderness and a palpable, cord-like structure along the vein.Questions

This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.

This choice is correct. The client's symptoms of fever, tachycardia, and hypotension are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.

This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.

This choice is correct. The client's symptoms of fever, chills, confusion, low blood pressure, and mottled skin are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.

This choice is incorrect because sepsis typically presents with systemic symptoms like fever, chills, and confusion, not localized symptoms along the vein path.Questions

This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.

This choice is incorrect because Type IV (Delayed) hypersensitivity reactions occur 24 to 72 hours after exposure to an allergen and are mediated by T cells, leading to localized skin reactions like contact dermatitis. They are not associated with the rapid onset of symptoms described by the client.

This choice is correct. A thorough allergy assessment is essential in a client with a history of multiple drug allergies to identify potential allergens and prevent exposure to allergenic medications. The nurse should communicate allergies to the healthcare team and document them in the client's med

This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.

This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate.

This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

This choice is incorrect because increasing the IV flow rate to hasten medication infusion does not prevent medication incompatibilities. It is essential to confirm compatibility before administering the medications.

<p>This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.</p>

<p>This choice is incorrect because an air embolism is not associated with symptoms of swelling and coolness at the IV site.</p>

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Infiltration and Extravasation

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client receiving IV medication complains of sudden chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication of IV therapy? A Phlebitis B Infiltration C Fluid overload D Air embolism Click to see answer

Correct Answer is D

Explanation

A client receiving IV fluids complains of a cool sensation around the insertion site, and the nurse observes swelling and blanching of the skin. Which complication of IV therapy should the nurse suspect? A Phlebitis B Infiltration C Fluid overload D Catheter occlusion Click to see answer

Correct Answer is B

Explanation

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A client receiving IV medications develops a painful, warm, and red streak along the arm near the IV site. The nurse should recognize these symptoms as potential signs of which complication of IV therapy? A Phlebitis B Infiltration C Thrombophlebitis D Fluid overload Click to see answer

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A client with a history of heart failure is receiving IV fluids. The nurse should closely monitor the client for which potential complication? A Infiltration B Phlebitis C Fluid overload D Air embolism Click to see answer

Correct Answer is C

Explanation

A client receiving IV antibiotics develops sudden onset dyspnea, chest pain, and cyanosis. The nurse should suspect which complication of IV therapy? A Phlebitis B Infiltration C Fluid overload D Pulmonary embolism Click to see answer

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A nurse is caring for a client receiving IV fluids and observes the client experiencing chills, fever, and elevated heart rate. The nurse should suspect which complication of IV therapy? A Infiltration B Phlebitis C Fluid overload D Sepsis Click to see answer

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A client with chronic kidney disease is receiving IV therapy with a potassium-containing solution. The nurse should carefully monitor the client for which complication? A Hypokalemia B Hyperkalemia C Hypocalcemia D Hyponatremia Click to see answer

Correct Answer is B

Explanation

Correct Answer is B

Explanation

Correct Answer is D

Explanation

Correct Answer is D

Explanation

Correct Answer is B

Explanation

Correct Answer is A

Explanation

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication? A Infiltration B Phlebitis C Fluid overload D Thrombophlebitis Click to see answer

A nurse is caring for a client with a peripheral IV catheter in place. The client complains of tenderness and a palpable, cord-like structure along the vein. The nurse should suspect which complication of IV therapy? A Infiltration B Phlebitis C Fluid overload D Thrombophlebitis Click to see answer

A client receiving IV therapy develops a fever, chills, and malaise. The nurse notices red streaks along the vein path. Which complication of IV therapy should the nurse suspect? A Infiltration B Phlebitis C Sepsis D Thrombophlebitis Click to see answer

A client receiving IV fluids develops a fever, tachycardia, and hypotension. The nurse should recognize these symptoms as potential signs of which complication of IV therapy? A Infiltration B Phlebitis C Fluid overload D Sepsis Click to see answer

A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. The nurse should suspect which complication of IV therapy? A Infiltration B Phlebitis C Infection D Thrombophlebitis Click to see answer

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy? A Infiltration B Phlebitis C Thrombophlebitis D Sepsis Click to see answer

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action? A Phlebitis B Air embolism C Fluid overload D Infiltration Click to see answer

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect? A Phlebitis B Infiltration C Fluid overload D Air embolism Click to see answer

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