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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. "I'll be glad when I can stop taking this medicine.": This statement indicates a misunderstanding about phenytoin therapy. Phenytoin is typically a long-term medication used to prevent seizures, and it is not typically discontinued unless under the guidance of a healthcare provider. The nurse should clarify that stopping the medication abruptly can lead to rebound seizures and should emphasize the importance of continuing the medication as prescribed.
B. "I have made an appointment to see my dentist next week.": This statement indicates appropriate understanding, as regular dental check-ups are important for individuals taking phenytoin due to the medication's potential side effect of gingival hyperplasia.
C. "I know that I cannot switch brands of this medication.": This statement demonstrates understanding, as different brands of phenytoin can have variations in bioavailability, which can affect seizure control. It is important for clients to remain consistent with the same brand or formulation unless directed otherwise by their healthcare provider.
D. "I will notify my doctor before taking any other medications.": This statement indicates understanding of the potential for drug interactions with phenytoin, as it is a hepatic enzyme inducer and can affect the metabolism of other medications. Clients should always consult their healthcare provider before taking any new medications or supplements to ensure compatibility with phenytoin therapy.
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