Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Infiltration
This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with chest pain, dyspnea, and tachycardia.
B. Phlebitis
This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with chest pain, dyspnea, and tachycardia.
C. Fluid overload
This choice is incorrect because fluid overload does not typically cause chest pain, dyspnea, and tachycardia but rather manifests as symptoms such as elevated blood pressure, jugular vein distention, and edema.
D. Thrombophlebitis
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, which presents with chest pain and dyspnea.
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 infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with chest pain, dyspnea, and tachycardia.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with chest pain, dyspnea, and tachycardia.
C) This choice is incorrect because fluid overload does not typically cause chest pain, dyspnea, and tachycardia but rather manifests as symptoms such as elevated blood pressure, jugular vein distention, and edema.
D) 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, which presents with chest pain and dyspnea.
Similar Questions
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
This choice is incorrect because infiltration is characterized by swelling, coolness, and pallor around the insertion site, not a palpable, cord-like structure along the vein.
B. Phlebitis
This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not a palpable, cord-like structure.
C. Fluid overload
This choice is incorrect because fluid overload is not associated with a palpable, cord-like structure along the vein . It may cause generalized edema and increased blood pressure.
D. Thrombophlebitis
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.
Full Explanation
A) This choice is incorrect because infiltration is characterized by swelling, coolness, and pallor around the insertion site, not a palpable, cord-like structure along the vein.
B) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not a palpable, cord-like structure.
C) This choice is incorrect because fluid overload is not associated with a palpable, cord-like structure along the vein . It may cause generalized edema and increased blood pressure.
D) 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.
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
This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with fever, chills, and malaise.
B. Phlebitis
This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, not red streaks along the vein path.
C. Sepsis
This choice is correct. The client's symptoms of fever, chills, malaise, and red streaks along the vein path are indicative of sepsis, which is a severe infection that can occur as a complication of IV therapy. Red streaks along the vein path may indicate the spread of infection along the vein.
D. Thrombophlebitis
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
Full Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with fever, chills, and malaise.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, not red streaks along the vein path.
C) This choice is correct. The client's symptoms of fever, chills, malaise, and red streaks along the vein path are indicative of sepsis, which is a severe infection that can occur as a complication of IV therapy. Red streaks along the vein path may indicate the spread of infection along the vein.
D) 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
A nurse is caring for a client with an IV catheter in place for medication administration. The client reports tenderness, redness, and warmth around the insertion site. The nurse observes purulent drainage at the site. 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 and is not associated with purulent drainage and redness.
B. Phlebitis
This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, but it does not cause purulent drainage.
C. Infection
This choice is correct. The client's symptoms of tenderness, redness, warmth, and purulent drainage around the insertion site are indicative of an infection, which can occur as a complication of IV therapy if bacteria enter the bloodstream through the catheter.
D. Thrombophlebitis
This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.
Full Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with purulent drainage and redness.
B) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, but it does not cause purulent drainage.
C) This choice is correct. The client's symptoms of tenderness, redness, warmth, and purulent drainage around the insertion site are indicative of an infection, which can occur as a complication of IV therapy if bacteria enter the bloodstream through the catheter.
D) This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.