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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Administering antibiotics is a primary intervention for AGN when it is caused by a bacterial infection, such as post-streptococcal glomerulonephritis. Antibiotics help eliminate the infection and prevent further damage to the glomeruli.
Choice B Reason:
Encouraging increased fluid intake is not typically recommended for AGN, especially if the client has oliguria or edema, which are common in this condition. Fluid intake may need to be restricted to prevent fluid overload and worsening of hypertension.
Choice C Reason:
Frequent ambulation is not a priority intervention for AGN. While maintaining mobility is important, it does not directly address the renal inflammation or potential complications associated with AGN.
Choice D Reason:
Obtaining weight weekly is important for monitoring fluid status, but it is not the primary intervention. Daily weight measurements are more indicative of fluid retention or loss and are essential for closely monitoring the client's fluid balance.
Correct Answer is D
Explanation
Choice A reason:
Immunoglobulin G (IgG) is the most common type of antibody found in blood circulation and is involved in the body's immune response to fight infections. However, IgG is not typically associated with allergic reactions, which are immediate hypersensitivity reactions.
Choice B reason:
Immunoglobulin A (IgA) plays a critical role in mucosal immunity and is found in high concentrations in the mucous membranes, particularly those lining the respiratory passages and gastrointestinal tract. Like IgG, IgA is not primarily responsible for the allergic response seen in conditions such as seasonal allergies.
Choice C reason:
Immunoglobulin M (IgM) is usually the first antibody produced by the immune system when it detects an infection. IgM antibodies are larger and are involved in the primary immune response but are not the antibodies that mediate typical allergic reactions.
Choice D reason:
Immunoglobulin E (IgE) is the antibody that plays a central role in the pathophysiology of allergic diseases, including seasonal allergies. IgE antibodies are produced as a response to allergens and are responsible for the symptoms of an allergic reaction. An elevation in IgE levels typically indicates a positive result for an allergy test such as RAST.
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