A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as grade level 1. Which of the following assessment findings correlates with a grade level of 1?
Purulent drainage at the intravenous site access site.
Redness at the intravenous access site with pain.
Red streaks on the affected extremity.
Palpable venous cord in the affected extremity.
The Correct Answer is B
Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.
Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.
Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.
Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The statement that symptoms can worsen with penile penetration during intercourse is partially correct. While sexual activity may exacerbate feelings of bulging or discomfort associated with uterine prolapse, it does not typically worsen the prolapse itself⁹. Painful intercourse, known as dyspareunia, is a common symptom of pelvic organ prolapse, which includes uterine prolapse.
Choice B reason:
Feeling a sensation of pressure in the pelvis is a classic symptom of uterine prolapse. As the uterus descends into the vaginal canal, it can create a sensation of fullness or pressure that is often noticeable and uncomfortable for the patient.
Choice C reason:
Low back pain is indeed a symptom that can be associated with uterine prolapse. The weakening of pelvic floor muscles and ligaments that leads to prolapse can also contribute to discomfort in the lower back.
Choice D reason:
The presence of feces in the vagina would not be a direct symptom of uterine prolapse. However, a related condition called rectocele, where the rectum bulges into the vagina, could cause such a symptom. This condition is different from uterine prolapse and would require separate management.
Correct Answer is D
Explanation
Choice A reason:
Measuring the circumference of the thigh can be part of the assessment for swelling or edema, which may indicate compartment syndrome or other issues. However, it is not a direct measure of neurovascular status, which focuses on blood flow and nerve function.
Choice B reason:
Palpating the femoral pulse is important for assessing blood flow to the leg, but for a midshaft femur fracture, more distal pulses such as the popliteal, dorsalis pedis, or posterior tibial pulses would be more indicative of the neurovascular status of the affected limb.
Choice C reason:
Monitoring the client's calf for edema is a useful technique for identifying signs of swelling that could suggest complications like deep vein thrombosis or compartment syndrome. However, it does not provide a complete picture of neurovascular integrity, which also includes sensory and motor function assessment.
Choice D reason:
Instructing the client to wiggle his toes is a direct assessment of motor function, which is a key component of neurovascular status. This action, along with checking for sensation and capillary refill, helps to determine if there is any impairment in nerve function or blood supply to the affected area.
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