A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)
Damp dressing
Warmth at insertion site
Streak formation
Throbbing
Erythema
Correct Answer : B,C,D,E
Answer: (B, C, D, E)
Rationale:
A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.
B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.
C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.
D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.
E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.
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Related Questions
Correct Answer is C
Explanation
A. Brain natriuretic peptide - Brain natriuretic peptide (BNP) is primarily used to diagnose heart failure and assess its severity. It is not routinely monitored in clients taking lithium.
B. Erythrocyte sedimentation rate - Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and is not specifically related to lithium therapy monitoring.
C. Thyroid hormone assay - Monitoring thyroid function is essential in clients taking lithium because lithium can affect thyroid function, leading to hypothyroidism or hyperthyroidism. Therefore, checking thyroid hormone levels (T3, T4, and TSH) is important before administering lithium.
D. Liver function tests - While lithium can affect liver function in some cases, routine monitoring of liver function tests is not typically required for clients taking lithium. However, periodic liver function tests may be ordered if clinically indicated or if the client has underlying liver disease.
Correct Answer is D
Explanation
A. Protamine: Protamine is used as an antidote for heparin, not for benzodiazepines.
B. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioids, such as morphine or heroin. It does not antagonize the effects of benzodiazepines.
C. Diphenhydramine: Diphenhydramine is an antihistamine medication commonly used for allergy relief and as a sleep aid. It does not antagonize the effects of benzodiazepines.
D. Flumazenil: Flumazenil is a benzodiazepine receptor antagonist. It is used to reverse the effects of benzodiazepine overdose or to rapidly reverse the sedative effects of benzodiazepines in cases such as anesthesia recovery. Therefore, it is the correct option for antagonizing benzodiazepines.
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