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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","D","E"]

Explanation

Tardive dyskinesia (TD) is a potential adverse effect associated with long-term use of antipsychotic medications like haloperidol. It manifests as involuntary, repetitive movements, primarily involving the face, mouth, and tongue. The nurse should suspect tardive dyskinesia when observing the following manifestations:

A. Involuntary pelvic rocking and hip thrusting movements: These movements are characteristic of tardive dyskinesia and indicate abnormal involuntary motor activity.

B. Urinary retention and constipation: These are not typical manifestations of tardive dyskinesia. Urinary retention and constipation can be side effects of anticholinergic medications but are not associated with tardive dyskinesia.

C. Fine hand tremors and pill rolling: These manifestations are more characteristic of parkinsonism, which can be a side effect of antipsychotic medications but is distinct from tardive dyskinesia.

D. Tongue thrusting and lip smacking: These are classic manifestations of tardive dyskinesia and indicate abnormal involuntary movements of the tongue and lips.

E. Facial grimacing and eye blinking: These are also common manifestations of tardive dyskinesia, involving involuntary movements of the face, including grimacing and blinking of the eyes.

A. Give the medication. B. Discard the medication. C. Notify the provider. D. Return the medication to the pharmacy.

Correct Answer is B

Explanation

A. Give the medication: Administering expired medication poses potential risks to the client's safety and efficacy of treatment. Therefore, giving the medication is not appropriate.

B. Discard the medication: Expired medications may have decreased potency or even become harmful due to chemical changes over time. It is essential to discard expired medications to ensure client safety and maintain the effectiveness of treatment.

C. Notify the provider: While it's important to communicate issues related to medication administration to the healthcare provider, in this case, the expired medication should not be used regardless of provider notification.

D. Return the medication to the pharmacy: Returning expired medication to the pharmacy might be appropriate in some settings, but it is not the primary action to take in this situation. The priority is to ensure the client does not receive expired medication.

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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 nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give?

A nurse is preparing to administer haloperidol 5 mg IM to a client. The amount available is haloperidol 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

A charge nurse is teaching a group of nurses about the antagonist action of medications. The nurse should include in the teaching that which of the following antagonist medications is used for benzodiazepines?