Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Applying a warm compress to the IV site.
This choice is incorrect because applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.
B. Limiting the use of the affected arm for IV insertion.
This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.
C. Avoiding the use of a tourniquet during IV insertion.
This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.
D. Selecting a small-gauge catheter for the IV insertion.
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 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 applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.
B) This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.
C) This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.
D) 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.
Similar Questions
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
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.
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.
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.
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