A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?
The client reports numbness at the site.
Purulent drainage noted from the site
Skin over the site is sloughing
The vein appears cord-like
The Correct Answer is B
A) The client reports numbness at the site: Numbness at the insertion site is not a typical finding of infection. It may indicate nerve damage or another issue but is not specific to infection.
B) Purulent drainage noted from the site: Purulent drainage, characterized by pus-like discharge, is a common sign of infection at the insertion site of an intravenous catheter. It suggests the presence of bacteria and inflammation at the site.
C) Skin over the site is sloughing: Sloughing of the skin may occur with severe tissue damage but is not specific to infection. It could indicate other complications such as tissue necrosis or chemical irritation.
D) The vein appears cord-like: A cord-like appearance of the vein, known as thrombophlebitis, can occur with or without infection. It indicates inflammation and clot formation within the vein, which can be a complication of intravenous catheter insertion, but it does not specifically indicate infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Flushed skin: Flushed skin is not typically associated with hyponatremia. Instead, hyponatremia may present with symptoms such as pallor or cool, clammy skin due to alterations in perfusion and fluid balance.
B) Fever: Fever is not a common manifestation of hyponatremia. Elevated body temperature is typically associated with conditions such as infection or inflammation rather than electrolyte imbalances like hyponatremia.
C) Nausea and vomiting: Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to neurological symptoms, including nausea and vomiting. These symptoms occur due to alterations in osmotic pressure and cellular swelling resulting from the relative excess of water compared to sodium in the extracellular fluid. Other neurological symptoms of hyponatremia can include headache, confusion, lethargy, and seizures.
D) Extreme thirst: Extreme thirst, or polydipsia, is more commonly associated with hypernatremia, which is characterized by a serum sodium level above 145 mEq/L. Hypernatremia results from dehydration or a deficit of body water relative to sodium, leading to increased thirst as the body attempts to restore fluid balance.
Correct Answer is D
Explanation
A. Chocolate milk:
Chocolate contains caffeine, which can contribute to sleep disturbances. It is not a recommended beverage for someone looking to decrease caffeine intake.
B. Diet cola:
Cola contains caffeine, even in diet versions, which can contribute to sleep disturbances. Therefore, it is not suitable for decreasing caffeine intake.
C. Brewed iced tea:
Brewed iced tea contains caffeine, which can interfere with sleep. It is not a suitable option for someone trying to reduce caffeine consumption.
D. Lemon-lime soda:
Lemon-lime sodas typically do not contain caffeine, making them a better choice for someone looking to reduce their caffeine intake and improve sleep.
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