Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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 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.
Similar Questions
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.
A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?
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.
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.