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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. Clamping the catheter: Clamping the catheter may interrupt the flow of fluids or medications, which could worsen the client's condition. This action is not appropriate as the first intervention.

B. Initiate oxygen therapy: Acute shortness of breath is a critical symptom that requires immediate intervention to ensure adequate oxygenation. Initiating oxygen therapy is the priority action to improve the client's oxygenation status while further assessment and interventions are conducted.

C. Auscultate breath sounds: Assessing breath sounds is an essential component of the assessment for a client experiencing shortness of breath. However, in this scenario, the priority is to ensure the client's oxygenation needs are met by initiating oxygen therapy first.

D. Position the client in left lateral Trendelenburg: Positioning the client in left lateral Trendelenburg may help optimize oxygenation by improving blood flow and ventilation-perfusion matching. However, this action is not the priority compared to initiating oxygen therapy, which directly addresses the client's respiratory distress.

A. "Gradually decrease the dose once tolerance to the effect is reached." B. "Take most of the daily dose at bedtime." C. "Take the medication with meals." D. "Distribute the doses evenly throughout the day."

Correct Answer is B

Explanation

A. "Gradually decrease the dose once tolerance to the effect is reached." - Gradually decreasing the dose may help mitigate daytime sedation, but it's not the most appropriate initial response. Additionally, it should be done under the guidance of a healthcare provider.

B. "Take most of the daily dose at bedtime." - This response is appropriate because diphenhydramine commonly causes drowsiness, and taking most of the dose at bedtime can help minimize daytime sedation.

C. "Take the medication with meals." - Taking diphenhydramine with meals may reduce the risk of gastrointestinal upset but is unlikely to significantly decrease daytime sedation.

D. "Distribute the doses evenly throughout the day." - This approach may not effectively minimize daytime sedation because diphenhydramine's sedative effects are prolonged and may persist throughout the day if taken at regular intervals. Taking most of the dose at bedtime is a more practical strategy.

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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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