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 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.
Correct Answer is D
Explanation
Children can often be resistant to taking medication, but offering them choices and involving them in the process can help promote cooperation. Here's the rationale for each option:
A. Tell the child it is candy: This strategy involves deception and can lead to trust issues if the child discovers the truth. It's not ethical or recommended to lie to a child about medication.
B. Tell the child he will have to have a shot instead: Threatening the child with a shot is coercive and can cause fear and anxiety. It's not an appropriate or therapeutic approach to encourage cooperation.
C. Hide the medication in a large dish of ice cream: While hiding medication in food may work for some children, it's important to ensure that the child consumes the entire dose. Additionally, it's essential to check with the healthcare provider or pharmacist to confirm that the medication can be taken with food. However, this approach may not address the underlying issue of the child's resistance to taking medication.
D. Offer the child a choice of taking the medication with juice or water: Offering the child a choice empowers them and gives them some control over the situation. By allowing the child to choose how they take the medication, they may feel more comfortable and cooperative. This approach respects the child's autonomy and can be an effective way to encourage cooperation while ensuring the medication is taken as prescribed.
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