Question 1

A client who has been discharged from a hospital for 48 hours reports pain at a previous infusion site. On inspection of the site, a nurse finds redness and tenderness along the vein. Which condition should the nurse suspect?

Accepted Answer

Postinfusion phlebitis is the inflammation of the vein that occurs within 48 to 72 hours after an infusion. The symptoms include redness, tenderness, and warmth at the site of infusion. Extravasation is the leakage of solution or medications from a vein into surrounding tissue, which causes pain and swelling at the site. Speed shock is a reaction to a rapid infusion of medication, which results in symptoms such as headache, chills, and fever. Bacterial phlebitis is a bacterial infection of the vein, which can result in redness, swelling, and pain at the site.

Question 2

A nurse is caring for a client who has a newly implanted port. For which complication, specifically associated with implanted ports, should the nurse observe?

Accepted Answer

Displacement of the septum is a specific complication associated with implanted ports, as it can occur during needle insertion or removal.

Question 3

A client complains to a nurse that his or her I.V. site is "sore." The nurse notes that the site is red and edematous, but there is no palpable cord or streak. Using the criteria for infusion phlebitis, what should the nurse document as the severity of this phlebitis?

Accepted Answer

According to the criteria for infusion phlebitis, redness, swelling and pain at the site without evidence of a palpable cord or streak warrants a 2+ rating. A 1+ rating would indicate mild erythema with or without slight edema or itching. A 3+ rating would include the presence of a palpable cord or streak, and a 4+ rating would indicate the presence of a palpable cord or streak with purulent drainage.

Question 4

A nurse assesses that a client has developed 2+ phlebitis at the site of a current peripheral I.V. infusion. Which action should be the nurse's first priority?

Accepted Answer

Discontinuing the I.V. catheter at the phlebitis site is the first priority as it prevents further complications such as infection and thrombosis. The physician may be notified after the catheter has been discontinued. Starting a new line proximal to the old site and applying warm moist packs may be appropriate interventions after the site has been discontinued, but discontinuing the catheter is the priority.

Question 5

A nurse suspects that a client with a peripheral access device is experiencing a venous spasm. Which report by the client should prompt the nurse to suspect this condition?

Accepted Answer

Sharp pain extending from the site of infusion is a common symptom of a venous spasm, which can occur when the peripheral access device irritates the vein. Redness, a cold feeling, and increased temperature at the infusion site may be signs of infection or inflammation, but are not specific to a venous spasm.

Question 6

A nurse attempts to withdraw a blood sample for laboratory analysis from a central venous catheter (CVC) and is unsuccessful due to an aspiration occlusion. What could potentially be causes of an aspiration occlusion?

Accepted Answer

Catheter migration, a fibrin tail, or the catheter tip pressing against the vein wall can all cause aspiration occlusion by obstructing the flow of blood into the catheter.

Question 7

Upon inspection of a client's peripheral I.V. site, a nurse notes 3+ phlebitis of the client's vein. Which action by the nurse is most appropriate?

Accepted Answer

The answer of Upon inspection of a client's peripheral I.V....

Question 8

A nurse is assisting in the placement of a client's central venous catheter. The nurse is aware that the major complication that can occur during placement of a central venous access device is:

Accepted Answer

Intravascular and extravascular malpositioning is the major complication that can occur during placement of a central venous access device. This can lead to a variety of issues including difficulty in obtaining blood samples, incorrect medication delivery, and damage to surrounding tissues. Phlebitis, infiltration, and fibrin sheath formation can also occur, but they are not the major complication.

Question 9

A nurse on a medical-surgical unit is caring for multiple clients. Which clients should the nurse monitor closely for signs of phlebitis because they are at increased risk?

Accepted Answer

The answer of A nurse on a medical-surgical unit is...

Question 10

Which complication of I.V. therapy should a nurse suspect if a client has a fluctuating fever, chills, malaise, tachycardia, tachypnea, hypotension, and altered mental status?

Accepted Answer

The symptoms described indicate a systemic infection, which is consistent with septicemia. Local infection would cause redness and warmth at the site of the IV insertion, but the symptoms described are more severe and generalized. Thrombophlebitis would cause tenderness, redness, and swelling along the vein, but would not typically cause fever or altered mental status. Inflammatory response syndrome may present with similar symptoms, but septicemia is a more likely and specific complication of IV therapy.

Question 11

A nurse is caring for a client who has lipid deposits occluding his or her central line. Which declotting agent should the nurse use to clear lipid deposits from a central line?

Accepted Answer

70% ethanol is effective in clearing lipid deposits from central lines. Other options like hydrochloric acid, sodium bicarbonate, and alteplase are not specifically used for lipid deposits. Alteplase is commonly used for blood clots, not lipid deposits.

Question 12

A nurse is caring for multiple clients with I.V. access devices. The nurse carefully assesses each client for signs of local complications. For which systemic complication should the nurse observe?

Accepted Answer

Speed shock is a systemic complication that can occur with rapid administration of intravenous fluids or medications. The nurse should monitor clients for signs of hypotension, tachycardia, dyspnea, chest pain, or other symptoms of an allergic reaction or circulatory overload. Local complications such as phlebitis, hematoma, and extravasation should also be monitored for and addressed, but they are not systemic complications.

Question 13

A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin hydrochloride. The nurse notes that the I.V. site is warm, edematous, and indurated. The nurse also observes red streaking of the skin, peau d'orange skin, and vesicles. Based on this information, which condition should the nurse suspect?

Accepted Answer

The symptoms described, such as warm, edematous, indurated site, red streaking, peau d'orange skin, and vesicles, are indicative of extravasation, where the medication has leaked into the surrounding tissue causing irritation and damage.

Question 14

A nurse priming an I.V. administration set uncaps the distal end to attach a needleless device. Before attachment, the administration set falls and hits the countertop. Which action should be taken by the nurse?

Accepted Answer

Dropping the administration set may have caused contamination to the entire set. Therefore, it should be changed to ensure patient safety.

Question 15

Upon inspection of a client's peripheral I.V. site, a nurse notes 2+ phlebitis of the client's vein. Which action by the nurse is most appropriate?

Accepted Answer

Discontinuing the cannula is the most appropriate action in the case of 2+ phlebitis. Applying heat to the site may provide temporary relief but will not resolve the issue. Flushing the cannula with 0.9% sodium chloride is not an appropriate intervention for phlebitis. Watching and documenting observations is important but does not address the issue at hand.

Question 16

A nurse in an intensive care unit is caring for a client who has lipid deposits in her central line. Which agent should the nurse select to instill into the catheter in an attempt to dissolve the lipid deposits?

Accepted Answer

70% ethanol is effective in dissolving lipid deposits in central lines due to its ability to break down fats and oils.

Question 17

A nurse assesses the insertion site of a peripheral I.V. catheter and notes that the site is red, warm to touch, and slightly edematous proximal to the I.V. cannula. The client reports discomfort when the site is touched. The nurse should interpret that these signs are most likely due to:

Accepted Answer

The redness, warmth, and edema around the insertion site along with discomfort when touched are all classic signs of phlebitis, which is an inflammation of the vein. This can occur as a result of irritation from the catheter, chemical irritation from the I.V. solution, or from mechanical trauma to the vein during insertion. Venous spasm would not cause these symptoms, and hypersensitivity would present with different symptoms such as itching or a rash. Infiltration would present with swelling and coolness around the insertion site rather than warmth.

Question 18

A nurse in an intensive care unit is caring for a client who has an intraluminal obstruction of central line due to a thrombotic occlusion. Which declotting agent should the nurse select to remove the blood clots from a central line?

Accepted Answer

Alteplase is a thrombolytic agent that specifically works to dissolve blood clots. It is often used for declotting central lines and has been shown to be effective in treating thrombotic occlusions. Ethanol, sodium chloride, and sodium bicarbonate are not effective at declotting central lines.

Question 19

A client who has a central venous tunneled catheter for administration of chemotherapy presents to a hospital with a fluctuating fever, hypotension, profuse sweating, nausea, and explosive diarrhea. Based on this information, which condition should a nurse suspect?

Accepted Answer

The combination of fever, hypotension, sweating, nausea and diarrhea suggest sepsis which can occur as a complication of central venous catheterization.

Quiz 9: Complications of Infusion Therapy: Peripheral and Central Vascular Access Devices