71. A nurse enters a client's room to administer an IV medication and finds that the IV site is swollen, cool, and pale. The client reports discomfort at the insertion site. The nurse recognizes that this may be:
71. A nurse enters a client's room to administer an IV medication and finds that the IV site is swollen, cool, and pale. The client reports discomfort at the insertion site. The nurse recognizes that this may be:
Test-Taking Tip
What would be the expected color and skin temperature for each option? Only one of the options would be cool and pale.
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Interactions
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Answer 1 is correct because it is the only one that fits all four symptoms. Answer 2 is incorrect because with phlebitis the skin would be warm and red. Answer 3 is incorrect because sepsis is a systemic problem, not a localized complication. Answer 4 is incorrect because an allergic response is usually systemic, or if localized, it would produce redness.
