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 A
Explanation
Choice A reason:
The inability to abduct the arm at the shoulder is a classic sign of a rotator cuff injury. The rotator cuff is responsible for stabilizing the shoulder joint and aiding in various movements, including abduction. When there is a tear or significant weakness in the rotator cuff muscles, especially the supraspinatus muscle, the patient may be unable to lift the arm away from the body or may experience pain while doing so.
Choice B reason:
A negative drop arm test would actually indicate that there is no rotator cuff injury. The drop arm test is performed by asking the patient to fully abduct the arm to 90 degrees and then slowly lower it. If the patient can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the patient cannot control the descent of the arm, would suggest a rotator cuff tear.
Choice C reason:
While an alteration in the contour of the joint may indicate some form of shoulder pathology, it is not specific to a rotator cuff injury. Changes in the contour could be due to various conditions, including dislocation, arthritis, or other musculoskeletal disorders.
Choice D reason:
A positive Tinel's sign is used to diagnose nerve compression or nerve damage, not rotator cuff injuries. It is performed by tapping over the course of a nerve to elicit a tingling sensation or pain in the distribution of the nerve. This sign is commonly associated with conditions like carpal tunnel syndrome.
Correct Answer is A
Explanation
Choice A reason: Damage to cartilage and bone can progressively worsen. This is a characteristic of osteoarthritis. The disease is a degenerative joint disease that results in the loss of cartilage, which cushions the ends of bones in joints. As the disease progresses, the cartilage becomes thinner and may wear away entirely, causing the bones to rub against each other. This can result in pain, stiffness, and loss of joint movement.
Choice B reason:
Organ failure in later stages may occur without treatment. This statement is not typically associated with osteoarthritis. While osteoarthritis can significantly impact a person's quality of life, it does not directly cause organ failure. However, it's important to manage osteoarthritis effectively to maintain overall health and prevent secondary complications.
Choice C reason:
Inflammation will resolve over time. This is not typically true for osteoarthritis. While some people with osteoarthritis may experience periods of reduced symptoms, the underlying disease process does not resolve over time. In fact, osteoarthritis usually worsens over time.
Choice D reason:
There will be periods of flare-ups and remission of symptoms. This is true for many people with osteoarthritis. Symptoms can vary and may become more severe during periods of activity or stress on the joint. Conversely, symptoms may decrease during periods of rest or with effective management strategies.
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