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: Effective hand hygiene is the most important measure to prevent the transmission of hepatitis A, as the virus can be spread through close personal contact and by eating food or drinking water handled by someone who is infected¹. Handwashing with soap and water after using the bathroom, changing diapers, and before preparing or eating food is crucial.
Choice B reason: While avoiding raw foods can help prevent the transmission of various foodborne illnesses, hepatitis A is not commonly associated with raw foods unless they are contaminated during handling after cooking. However, it is still a good practice to avoid raw or undercooked foods in areas where hepatitis A is common.
Choice C reason:
Hepatitis A virus is primarily transmitted via the fecal-oral route, not through sexual contact. However, barrier protection can reduce the risk of transmission for many other infections, including other types of viral hepatitis that are sexually transmitted.
Choice D reason:
Eating at fast food restaurants is not inherently risky for hepatitis A transmission unless the food or water is contaminated. It is more important to ensure that all food is properly handled and cooked, regardless of the dining establishment.
Correct Answer is B
Explanation
Choice A reason:
Asking about dietary changes is relevant to a skin assessment, as diet can influence skin health. However, this question does not require intervention unless the dietary changes are directly related to the skin condition. If the client has been advised to follow a specific diet for their skin condition, then the nurse should ensure compliance with that diet.
Choice B reason:
This question shifts the focus from the skin condition’s characteristics and impact to general coping mechanisms. It does not help determine the lesion’s symptoms, triggers, or functional effects, and thus does not align with a targeted skin assessment framework, requiring intervention.
Choice C reason:
Exploring how the skin issue affects the client’s feelings reveals psychosocial stressors and the emotional burden of living with a visible condition. This insight supports holistic care planning, adherence strategies, and therapeutic rapport.
Choice D reason:
Sleep disturbances can be a consequence of skin conditions, especially if they involve itching or pain. This question is pertinent to the assessment and does not require intervention. The information gathered can help in formulating a comprehensive care plan that addresses the client's comfort and sleep quality.
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