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 {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
The rationale for identifying the client as at risk for hypoxia is based on the respiratory assessment findings. Diminished lung sounds in the posterior lobes suggest reduced air movement or potential complications such as atelectasis or pneumonia, which can impair gas exchange. Additionally, the decreased oxygen saturation of 84% on room air indicates inadequate oxygenation of the blood. Hypoxia occurs when there is insufficient oxygen supply to tissues, which can lead to serious complications if not addressed promptly. Therefore, recognizing these respiratory assessment findings is crucial for identifying the risk of hypoxia in the client.
Correct Answer is B
Explanation
A. The client's daughter, who is the primary caregiver: While the daughter may be involved in the client's care and decision-making process, the client themselves should provide informed consent if they have decision-making capacity. Informed consent cannot be provided by a caregiver unless legally authorized to do so.
B. The client: The client is alert, oriented, and has advance directives. In this scenario, the client possesses decision-making capacity and is capable of providing informed consent for the procedure. As long as the client is competent and able to understand the nature, risks, benefits, and alternatives of the procedure, they are the appropriate person to sign the informed consent document.
C. The client's partner: Unless legally designated as the client's healthcare proxy or legally authorized to provide consent on the client's behalf, the partner should not sign the informed consent document. The client themselves should provide consent if they have decision-making capacity.
D. The client's son, who has a durable power of attorney: While a durable power of attorney grants legal authority to make healthcare decisions on behalf of the client if they lack decision-making capacity, it does not negate the client's ability to provide informed consent if they are competent to do so. If the client is alert, oriented, and capable of understanding the procedure, they should sign the informed consent document themselves.
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