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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Dysrhythmias:
Straining while defecating can trigger the Valsalva maneuver, which involves taking a deep breath and bearing down. This can lead to increased intrathoracic pressure, decreased venous return to the heart, and subsequently a sudden drop in blood pressure when the strain is released. These changes can cause cardiac dysrhythmias, particularly in older adults or those with underlying heart conditions.
B) Dilated pupils:
Dilated pupils are not a known consequence of straining while defecating. Pupillary dilation is typically associated with responses to low light, certain medications, or neurological conditions, rather than gastrointestinal strain.
C) Gastric ulcer:
Gastric ulcers are caused by factors such as Helicobacter pylori infection, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive stomach acid. Straining during defecation does not contribute to the development of gastric ulcers.
D) Diarrhea:
Straining while defecating is more likely to be associated with constipation rather than diarrhea. Diarrhea involves frequent, loose, or watery stools, whereas straining typically occurs due to hard stools and difficulty passing them.
Correct Answer is ["A","B","C","D"]
Explanation
A) Bright light: Exposure to bright light, especially in the evening or at night, can interfere with the body's production of melatonin, a hormone that regulates the sleep-wake cycle. Bright light exposure can disrupt circadian rhythms, making it more challenging to fall asleep and stay asleep.
B) Drinking caffeinated beverages in the evening: Caffeine is a stimulant that can interfere with sleep by blocking the effects of adenosine, a neurotransmitter that promotes sleepiness. Consuming caffeinated beverages in the evening can delay the onset of sleep and reduce overall sleep duration.
C) A 20-minute nap during the day: While short naps can be beneficial for some individuals, especially if they are sleep-deprived, napping for too long or too late in the day can disrupt the body's natural sleep-wake cycle. Short naps can be refreshing, but longer or late-day naps can make it harder to fall asleep at night.
D) Emotional stress: Stress and anxiety can trigger the body's "fight or flight" response, leading to increased alertness and difficulty relaxing or falling asleep. Chronic stress can disrupt the sleep-wake cycle, leading to difficulty initiating or maintaining sleep and resulting in poor sleep quality.
E) A regular bedtime schedule: Having a consistent bedtime schedule can actually help regulate the sleep-wake cycle by reinforcing the body's internal clock. Going to bed and waking up at the same time each day, even on weekends, can help improve sleep quality and make it easier to fall asleep and wake up naturally.
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