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 D
Explanation
A. The client's blood pressure is within the expected reference range - While blood pressure monitoring is important during treatment with certain medications, such as antihypertensives, it is not a direct indicator of the effectiveness of sertraline, which is an antidepressant medication.
B. The client's legs are not swollen - Swelling of the legs may be a sign of fluid retention, which can occur with various conditions and medications. However, it is not a specific indicator of the effectiveness of sertraline.
C. The client reports a recent weight loss - Weight changes, including weight loss or gain, can occur as side effects of sertraline. However, weight changes alone do not necessarily indicate the effectiveness of the medication in treating depression.
D. The client reports an increase in mood - Improvement in mood, reduction in depressive symptoms, and overall sense of well-being are primary indicators of the effectiveness of sertraline and other antidepressant medications in treating depression. Therefore, the client reporting an increase in mood suggests that the medication may be effective in managing their symptoms.
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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