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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. The client demonstrated an allergic response to the medication: While allergic reactions to disulfiram can occur, severe nausea and vomiting after taking the medication are more likely due to its interaction with alcohol rather than an allergic response.

B. The client consumed alcohol while taking the medication: Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. Severe nausea and vomiting are common adverse effects of consuming alcohol while on disulfiram.

C. The client took an overdose of the medication: An overdose of disulfiram could potentially lead to severe adverse effects, but nausea and vomiting alone are not typically indicative of an overdose.

D. The client experienced a common side effect of the medication: While nausea and vomiting are common side effects of disulfiram, they are typically experienced in response to alcohol consumption rather than as direct effects of the medication itself.

A. Speak to the provider about adding an MAOI to the current medication regimen. B. Tell the client that the provider will need to change citalopram to a different medication. C. Explain that antidepressants often take several weeks to be fully effective. D. Recommend a sleep study be done on the client.

Correct Answer is C

Explanation

A. Speaking to the provider about adding an MAOI to the current medication regimen: MAOIs (Monoamine oxidase inhibitors) are typically considered as second- or third-line treatments due to their potential for serious side effects and interactions with other medications. It is not the first-line approach to managing depressive symptoms that have not improved with citalopram alone.

B. Telling the client that the provider will need to change citalopram to a different medication: It's premature to switch medications after only two weeks, as antidepressants often take several weeks to exert their full therapeutic effect. It's essential to allow adequate time for the current medication regimen to work before considering a change.

C. Explaining that antidepressants often take several weeks to be fully effective: This is the most appropriate action. It's important for the nurse to educate the client about the delayed onset of action of antidepressants and reassure them that improvement may take time. Adjustments to the dosage or switching to a different medication would typically be considered if there is no improvement after a sufficient trial period.

D. Recommending a sleep study be done on the client: While sleep disturbances are common in depression, recommending a sleep study would be premature at this stage. It's essential to address the underlying depressive symptoms first, as they may contribute to the sleep disturbance.

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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.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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