A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

Thrombophlebitis

Infiltration

Infection

Extravasation

Answer and Explanation

The Correct Answer is A

Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.

Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.

Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.

Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.

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Correct Answer is B

Explanation

Choice A Reason:

Listening to the client’s speech is not a method used to assess cranial nerve V. This method is more relevant for assessing cranial nerves IX (Glossopharyngeal) and X (Vagus), which are involved in speech and swallowing.

Choice B Reason:

Asking the client to identify scented aromas is a method used to assess cranial nerve I (Olfactory), not cranial nerve V. Cranial nerve V (Trigeminal) is assessed by testing facial sensation and motor functions such as chewing.

Choice C Reason:

Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V

Choice D Reason:

Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.

A. Position the collection device below the level of the chest. B. Clamp the tube when providing care activities. C. Apply an occlusive dressing over the chest tube site. D. Empty the chest tube collection chamber every shift.

Correct Answer is A

Explanation

Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.

Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.

Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.

Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.

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A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

Correct Answer is B

Explanation

A nurse is caring for a client with a chest tube. Which action should the nurse take?

Correct Answer is A

Explanation

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A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

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