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    Rn ati comprehensive predictor 2023 proctored exam

    A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

    Explanation & Rationale

    A) Phlebitis: The presence of redness and warmth around the peripheral catheter insertion site is indicative of phlebitis, which is inflammation of the vein. This condition can result from mechanical irritation, chemical irritation from the infusion, or infection. It is crucial to monitor and document these findings promptly. B) Extravasation: This occurs when intravenous (IV) fluids or medications leak into the surrounding tissue, causing tissue damage. Symptoms typically include pain, swelling, and possible blistering, rather than just redness and warmth. C) Infiltration: This refers to the unintentional infusion of fluid into the surrounding tissue due to the catheter becoming dislodged or puncturing the vein. It is characterized by swelling, coolness, and tenderness at the site rather than warmth and redness. D) Circulatory overload: This condition results from excessive fluid volume in the circulatory system, leading to symptoms such as shortness of breath, hypertension, and peripheral edema. It is not associated with localized redness and warmth at the catheter site.

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