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.

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Correct Answer is A

Explanation

Choice a) Raloxifene:
Raloxifene is part of a class of drugs known as selective estrogen-receptor modulators (SERMs). It works by imitating the beneficial effects of the hormone estrogen on your bones, helping to prevent bone loss and improve density. Therefore, it is used in the prevention and treatment of osteoporosis.

Choice b) Calcitonin:
Calcitonin is a hormone that a person’s thyroid gland produces. It helps regulate the amount of calcium in the body. For the treatment of postmenopausal osteoporosis, scientists typically extract calcitonin from salmon. This is because salmon calcitonin has a much higher potency than human calcitonin. Osteoclasts are cells in the body that degrade bone. Calcitonin can inhibit osteoclasts. This helps slow the loss of bone density and increases bone mass, hindering the progression of osteoporosis.

Choice c) Allopurinol:
Allopurinol is primarily used to treat gout and certain types of kidney stones. It is not typically used in the prevention or treatment of osteoporosis.

Choice d) Levothyroxine:
Levothyroxine is used to treat hypothyroidism (underactive thyroid). It is not typically used in the prevention or treatment of osteoporosis. However, if you are prescribed levothyroxine you should have regular blood tests, at least once a year, to ensure your thyroid hormone levels are not too high. Continuous high thyroid hormone levels may lead to developing or worsening of low bone density and osteoporosis.

A. Location of the burn B. Age of the client C. Cause of the burn D. Associated medical history

Correct Answer is A

Explanation

Choice A reason:
The location of the burn is crucial in assessing the severity because burns to the face, neck, and upper extremities can compromise vital functions. For example, burns to the face may affect the airway and respiratory system, while burns to the hands can impair mobility and the ability to perform daily tasks. The depth of the burn at these locations also affects the severity assessment, as deeper burns can damage underlying tissues and structures.

Choice B reason:
While the age of the client can influence the healing process and the risk of complications, it is not the primary factor in assessing the initial severity of the burn. However, age is considered when planning treatment and rehabilitation, as children and the elderly may have different healing rates and responses to therapy.

Choice C reason:
The cause of the burn can provide context for potential complications, such as inhalation injury from a fire or chemical exposure. However, the immediate assessment of severity is more focused on the observable damage to the skin and underlying tissues rather than the cause of the burn.

Choice D reason:
The client's associated medical history is important for understanding potential risks and complications during the healing process, but it is not the primary factor in assessing the severity of the burn. The medical history will be more relevant when considering the client's overall prognosis and planning long-term care.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis?

Correct Answer is A

Explanation

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is A

Explanation

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4+ T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

A nurse is planning to teach a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

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 fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP). The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?