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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 A

Explanation

A. Documents medication administration prior to administering it: Documenting medication administration before actually administering it is incorrect and can lead to errors in documentation. The nurse should document medication administration after ensuring the medication is given to the client.

B. Verifies the medication against the prescription and medication label: This is a correct action. The nurse should verify the medication against the prescription and medication label to ensure accuracy before administering it.

C. Checks the provider's orders and confirmed dosage in a medication reference guide: This is a correct action. The nurse should check the provider's orders and confirm the dosage in a reliable medication reference guide to ensure accuracy before administering the medication.

D. Scans the barcode on the medication administration record and the client's armband: This is a correct action. Scanning the barcode on the medication administration record and the client's armband helps ensure the "Five Rights" of medication administration: right patient, right medication, right dose, right route, and right time.

A. Protamine B. Naloxone C. Diphenhydramine D. Flumazenil

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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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

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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