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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:
Alendronate is a bisphosphonate, which is commonly prescribed for Paget's disease of the bone. Bisphosphonates help regulate bone growth and can be a lifelong medication for managing this condition. They work by inhibiting osteoclasts, the cells that break down bone tissue, which helps to normalize the bone remodeling process.

Choice B reason:
Colchicine is used to treat gout and not typically used for Paget's disease. It works by reducing the inflammation caused by uric acid crystals but does not affect the bone remodeling process that is characteristic of Paget's disease.

Choice C reason:
Allopurinol is also used to treat gout by decreasing uric acid production in the body. Like colchicine, it is not used to treat Paget's disease because it does not address the abnormal bone metabolism associated with the condition.

Choice D reason:
Prednisone is a corticosteroid used to reduce inflammation in various conditions. While it may be used in some cases to manage pain and inflammation associated with Paget's disease, it is not a primary treatment for the disease itself and does not regulate bone growth like bisphosphonates do.

A. Reinforce teaching about gargling with warm saline several times daily. B. Ask the client to identify friends and family who have been in close contact. C. Instruct the client to take antipyretics as directed for elevated temperature. D. Notify the client to return to the clinic for initiation of antibiotic therapy.

Correct Answer is D

Explanation

Choice A reason:
While gargling with warm saline can provide symptomatic relief for a sore throat, it does not address the underlying bacterial infection. Therefore, it is not the priority action once a diagnosis of group A streptococcus has been confirmed.

Choice B reason:
Identifying close contacts is important for public health tracking and potentially preventing the spread of the infection. However, the immediate priority for the client is the initiation of treatment to address the infection.

Choice C reason:
Taking antipyretics can help manage fever and provide comfort to the client. While managing symptoms is important, it is secondary to initiating antibiotic therapy, which addresses the cause of the symptoms.

Choice D reason:
The priority action is to notify the client to return to the clinic for initiation of antibiotic therapy. Group A streptococcus is a bacterial infection that requires antibiotics for treatment. Prompt initiation of antibiotics is crucial to prevent complications and promote recovery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a new diagnosis of Paget's disease. The nurse anticipates the provider will prescribe which of the following medications for this client?

Correct Answer is A

Explanation

A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?

A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?

A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan?

A nurse is caring for a client who has Stage IV lung cancer and was prescribed opioid medications for pain management. The client is unable to engage in most physical activities. Which of the following manifestations should the nurse anticipate?

A nurse is teaching a client who has a pelvic fracture about the manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?

A nurse is teaching a client who is to begin taking tamoxifen to treat breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication?

A nurse is providing teaching for a client who is preparing for a below-the-knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis?