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 B
Explanation
Choice A reason:
The statement about using a natural membrane condom rather than a polyurethane condom is incorrect. Natural membrane condoms, such as those made from lambskin, have small pores that can allow viruses to pass through. Therefore, they are not recommended for the prevention of STIs. Polyurethane condoms, on the other hand, do not have these pores and are considered effective in preventing STIs, including HIV.
Choice B reason:
Female condoms, also known as internal condoms, are effective in preventing the transmission of sexually transmitted viruses, including HIV. They act as a barrier to prevent the exchange of bodily fluids during sexual activity, thereby reducing the risk of STI transmission. It's important to include this information in the teaching as it empowers individuals with an additional option for protection.
Choice C reason:
Condoms are designed for single use only. Using a condom more than once greatly increases the risk of condom failure, which can lead to the transmission of STIs or unintended pregnancy. It is crucial to emphasize the importance of using a new condom for each act of sexual intercourse.
Choice D reason:
Oil-based lubricants should not be used with latex condoms as they can weaken the material, leading to condom breakage. Instead, water-based or silicone-based lubricants are recommended as they do not damage the condom and can help prevent breakage.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is: a. Temperature, c. Color, d. Sensation.
Choice A: Temperature
Reason: Monitoring the temperature of the affected extremity is crucial in evaluating neurovascular status. A cool or cold extremity can indicate decreased perfusion, which may be a sign of neurovascular compromise. Normal skin temperature should be warm to the touch, indicating adequate blood flow.
Choice B: Ecchymosis
Reason: Ecchymosis, or bruising, is not a direct indicator of neurovascular status. While it can provide information about trauma or bleeding, it does not assess the functionality of nerves or blood vessels in the affected extremity.
Choice C: Color
Reason: Assessing the color of the extremity is essential. Pallor or cyanosis can indicate poor blood flow or oxygenation, which are critical signs of neurovascular impairment. Normal color should be consistent with the rest of the body, indicating good circulation.
Choice D: Sensation
Reason: Evaluating sensation helps determine if there is any nerve damage or impairment. Changes in sensation, such as numbness or tingling, can indicate neurovascular compromise. Normal sensation should be intact and symmetrical with the unaffected extremity.
Choice E: Skin Integrity
Reason: While skin integrity is important for overall wound healing and infection prevention, it is not a primary parameter for assessing neurovascular status. It does not provide direct information about blood flow or nerve function.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.