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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

Answer and Explanation

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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Correct Answer is B

Explanation

A. "Gradually decrease the dose once tolerance to the effect is reached." - Gradually decreasing the dose may help mitigate daytime sedation, but it's not the most appropriate initial response. Additionally, it should be done under the guidance of a healthcare provider.

B. "Take most of the daily dose at bedtime." - This response is appropriate because diphenhydramine commonly causes drowsiness, and taking most of the dose at bedtime can help minimize daytime sedation.

C. "Take the medication with meals." - Taking diphenhydramine with meals may reduce the risk of gastrointestinal upset but is unlikely to significantly decrease daytime sedation.

D. "Distribute the doses evenly throughout the day." - This approach may not effectively minimize daytime sedation because diphenhydramine's sedative effects are prolonged and may persist throughout the day if taken at regular intervals. Taking most of the dose at bedtime is a more practical strategy.

A. Avoid flossing the teeth to prevent gum irritation. B. Alcohol increases the chance of phenytoin toxicity. C. Take an antacid with the medication if indigestion occurs. D. Phenytoin turns urine blue.

Correct Answer is B

Explanation

A. Avoid flossing the teeth to prevent gum irritation: There is no evidence to suggest that flossing the teeth increases the risk of gum irritation with phenytoin use. In fact, proper dental hygiene, including flossing, is essential to prevent gum disease, which can be exacerbated by the medication.

B. Alcohol increases the chance of phenytoin toxicity: Consumption of alcohol can increase the risk of phenytoin toxicity by enhancing its effects. Therefore, clients taking phenytoin should avoid alcohol consumption to prevent adverse effects and ensure the medication's efficacy.

C. Take an antacid with the medication if indigestion occurs: Phenytoin can interact with antacids, reducing its absorption and effectiveness. Therefore, clients should not take antacids concurrently with phenytoin unless directed by their healthcare provider.

D. Phenytoin turns urine blue: Phenytoin does not typically cause changes in urine color. This statement is incorrect and not relevant to the client's medication regimen.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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