Choice A reason: Infiltration. This is when the IV fluid leaks into the surrounding tissue, causing swelling, coolness, and pallor. This does not match the symptoms of redness, warmth, and tenderness.

Choice B reason:

Extravasation. This is when the IV fluid is a vesicant, meaning it can cause tissue damage or necrosis if it leaks into the surrounding tissue. This can cause pain, burning, blistering, or skin sloughing. This does not match the symptoms of redness, warmth, and tenderness.

Choice C reason:

Phlebitis. This is when the vein becomes inflamed due to mechanical, chemical, or bacterial irritation. This can cause redness, warmth, tenderness, and a palpable cord along the vein. This matches the symptoms of the client.

Choice D reason:

Thrombophlebitis. This is when a blood clot forms in the vein, causing inflammation and obstruction. This can cause pain, swelling, redness, warmth, and a palpable cord along the vein. However, this is more likely to occur in larger veins such as the femoral or saphenous veins, not in the cephalic vein.

Choice A reason:

Incorrect. Checking the patency of the catheter by flushing it with normal saline is not necessary for a central venous access device (CVAD) that is already in place and functioning. Flushing is done before and after each medication administration or every 8 hours when medications are not being given.

Choice B reason:

Correct. Using aseptic technique when accessing the catheter is essential to prevent catheter-related bloodstream infections (CRBSIs), which are a serious complication of CVADs. The nurse should wear gloves, mask, and gown and use sterile equipment when changing the dressing or tubing.

Choice C reason:

Incorrect. Applying pressure dressing over the insertion site is not recommended for a CVAD in the internal jugular vein. Pressure dressings can increase the risk of thrombosis and occlusion of the catheter. A transparent semipermeable dressing is preferred to allow for visualization of the site and prevent moisture accumulation.

Choice D reason:

Correct. Monitoring the client for signs of infection and air embolism is a vital action for the nurse to take when caring for a client with a CVAD. Signs of infection include fever, chills, redness, swelling, drainage, or tenderness at the insertion site. Signs of air embolism include dyspnea, chest pain, hypotension, tachycardia, or altered mental status. The nurse should promptly report any abnormal findings to the provider.

Choice E reason:

Correct. Changing the dressing and tubing according to facility protocol is another important action for the nurse to take to maintain the patency and integrity of the CVAD and prevent complications. The dressing should be changed every 5 to 7 days or more frequently if it becomes loose, wet, or soiled. The tubing should be changed every 72 to 96 hours or per manufacturer's recommendations.

Choice A reason:

This is incorrect because a burning sensation at the site is more likely to indicate phlebitis, which is inflammation of the vein, rather than infiltration, which is leakage of fluid into the surrounding tissue.

Choice B reason:

This is incorrect because blood leaking from the site is more likely to indicate a hematoma, which is a collection of blood outside the blood vessel, rather than infiltration.

Choice C reason:

This is correct because swelling and coolness around the site are common signs and symptoms of infiltration. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing edema and reduced blood flow.

Choice D reason:

This is incorrect because difficulty moving the arm is more likely to indicate nerve damage or compartment syndrome, which are serious complications of IV therapy, rather than infiltration.

Choice A reason:

Fever and chills are not signs of extravasation, but rather of infection or an allergic reaction to the antineoplastic medication.

Choice B reason:

Nausea and vomiting are common side effects of antineoplastic medications, but they are not caused by extravasation. Extravasation is the leakage of the medication into the surrounding tissues.

Choice C reason:

Tissue necrosis and deformity are possible consequences of extravasation, especially with vesicant drugs that can cause severe tissue damage. The nurse should monitor the client for pain, swelling, redness, or blistering at the infusion site and stop the infusion immediately if extravasation is suspected.

Choice D reason:

Hypotension and tachycardia are not specific signs of extravasation, but rather of shock or hemorrhage. The nurse should monitor the client's vital signs and report any abnormal findings to the primary health care provider.

Choice A reason:

Dehydration is not a risk factor for thrombophlebitis, which is inflammation of a vein due to a blood clot. Dehydration can cause hemoconcentration, which increases the risk of thrombosis, but not necessarily thrombophlebitis.

Choice B reason:

Immobility is a risk factor for thrombophlebitis, as it reduces blood flow and increases the chance of clot formation in the veins. Immobility can also impair the function of the calf muscles, which normally help pump blood back to the heart.

Choice C reason:

Hyperglycemia is not a risk factor for thrombophlebitis, although it can increase the risk of other vascular complications, such as atherosclerosis and peripheral arterial disease. Hyperglycemia can damage the endothelial lining of the blood vessels, but this does not directly cause thrombophlebitis.

Choice D reason:

Hypertension is not a risk factor for thrombophlebitis, although it can increase the risk of other cardiovascular problems, such as stroke and heart failure. Hypertension can increase the pressure and stress on the arterial walls, but this does not affect the venous system where thrombophlebitis occurs.