A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

Infiltration

Extravasation

Circulatory overload

Phlebitis

Answer and Explanation

The Correct Answer is D

Choice A reason:

Infiltration is not correct: Infiltration occurs when the infused fluid or medication leaks into the surrounding tissue instead of flowing into the vein. This can lead to swelling, coolness, and pallor around the insertion site.

Choice B reason:

Extravasation is not correct: Extravasation is similar to infiltration but specifically refers to the infiltration of vesicant medications, which can cause tissue damage and necrosis.

Choice C reason:

Circulatory overload is not correct: Circulatory overload occurs when a large volume of fluid is infused too quickly, overloading the circulatory system and potentially leading to fluid overload, pulmonary edema, and other related symptoms.

Choice D reason:

Phlebitis is the appropriate fingings. The nurse should document the finding of redness and warmth around the peripheral catheter insertion site as phlebitis. Phlebitis is the inflammation of a vein, often caused by mechanical irritation, chemical irritation, or infection. In this case, the redness and warmth at the insertion site are indicative of inflammation, which is a common sign of phlebitis.

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Correct Answer is A

Explanation

To calculate the percentage of weight loss, we can use the formula:

Percentage of weight loss = (Weight loss / Original weight) * 100

Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:

Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%

The percentage of weight loss is approximately 7.49%.

Since none of the provided answer options exactly match this calculated percentage, the closest option is:

So, the nurse should identify the weight loss as approximately 7.5%.

A. Physical assessment findings B. Family medical history C. Medications taken prior to admission D. Medical health insurance claims

Correct Answer is A

Explanation

Answer: A. Physical assessment findings

Rationale: Physical assessment findings are relevant information for a physical therapist, as they provide information about the client's mobility, strength, balance, coordination, pain, and functional status.

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A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is A

Explanation

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is A

Explanation

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