Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Phlebitis
This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.
B. Infiltration
This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.
C. Fluid overload
This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.
D. Extravasation
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.
This question is an excerpt from Nurse Dive's nursing test bank - Complications of Intravenous therapy. Take the full exam now
Full Explanation
A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.
B) This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.
C) This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.
D) 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.
Similar Questions
A nurse is caring for a client with an IV catheter in place for fluid administration. The nurse observes the client's arm is edematous, and the skin feels cool to the touch. The infusion is sluggish, and the client reports discomfort at the site. Which complication of IV therapy should the nurse suspect?
A. Phlebitis
This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not edema and coolness.
B. Infiltration
This choice is correct. The client's symptoms of edema, coolness, sluggish infusion, and discomfort at the site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.
C. Fluid overload
This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.
D. Air embolism
This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as edema and coolness around the IV site.
Full Explanation
A) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not edema and coolness.
B) This choice is correct. The client's symptoms of edema, coolness, sluggish infusion, and discomfort at the site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.
C) This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.
D) This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as edema and coolness around the IV site.
A client receiving IV therapy complains of pain and burning at the insertion site. The nurse notices the skin turning red and becoming tender. Which action should the nurse take first?
A. Stop the IV infusion immediately.
This choice is correct. The client's symptoms of pain, burning, redness, and tenderness at the insertion site are indicative of a potential complication, such as phlebitis or infiltration. The nurse should stop the IV infusion immediately to prevent further damage.
B. Elevate the arm to promote venous return.
This choice is incorrect because elevating the arm may not address the underlying complication of phlebitis or infiltration.
C. Apply a warm compress to the site for comfort.
This choice is incorrect because applying a warm compress is not the priority. The nurse should first stop the infusion to prevent complications.
D. Administer a prescribed analgesic.
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
Full Explanation
A) This choice is correct. The client's symptoms of pain, burning, redness, and tenderness at the insertion site are indicative of a potential complication, such as phlebitis or infiltration. The nurse should stop the IV infusion immediately to prevent further damage.
B) This choice is incorrect because elevating the arm may not address the underlying complication of phlebitis or infiltration.
C) This choice is incorrect because applying a warm compress is not the priority. The nurse should first stop the infusion to prevent complications.
D) 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
A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes redness, warmth, and swelling around the insertion site, and the client reports tenderness and pain. Which complication of IV therapy should the nurse suspect?
A. Infiltration
This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not redness, warmth, and tenderness around the insertion site.
B. Extravasation
This choice is incorrect because extravasation occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture, but it does not present with redness and swelling.
C. Phlebitis
This choice is correct. The client's symptoms of redness, warmth, swelling, tenderness, and pain around the insertion site are indicative of phlebitis, which is the inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.
D. Air embolism
This choice is incorrect because an air embolism is not associated with symptoms of phlebitis, such as redness and swelling around the IV site.
Full Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not redness, warmth, and tenderness around the insertion site.
B) This choice is incorrect because extravasation occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture, but it does not present with redness and swelling.
C) This choice is correct. The client's symptoms of redness, warmth, swelling, tenderness, and pain around the insertion site are indicative of phlebitis, which is the inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.
D) This choice is incorrect because an air embolism is not associated with symptoms of phlebitis, such as redness and swelling around the IV site.