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

Answer and Explanation

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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Correct Answer is C

Explanation

A) Exposed bone: Exposed bone is a manifestation of a stage 4 pressure ulcer, where full-thickness skin loss occurs, exposing muscle, tendon, or bone. In stage 3 pressure ulcers, the skin loss extends into the subcutaneous tissue, but it does not reach the level of exposing underlying structures like bone.

B) Blood-filled blisters: Blood-filled blisters can occur in various stages of pressure ulcers, but they are not specific to stage 3. They may be present in stage 1 or stage 2 pressure ulcers as well.

C) Necrotic subcutaneous tissue: This is the correct manifestation of a stage 3 pressure ulcer. Stage 3 pressure ulcers involve full-thickness skin loss with visible necrosis or damage to the subcutaneous tissue. The ulcer may appear as a deep crater with or without undermining of adjacent tissue.

D) Partial-thickness skin loss: Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, where the ulcer extends through the epidermis and into the dermis but does not involve deeper tissue layers like the subcutaneous tissue.

A. pulling the client up from under the arms B. improving the client's hydration C. lubricating the area with skin cream D. preventing the client from sliding in bed

Correct Answer is D

Explanation

A) Pulling the client up from under the arms: This action can increase shearing force on the client's skin, especially if done abruptly or without proper assistance. Pulling the client up by the arms can create friction and shear between the skin and underlying tissues, potentially worsening the pressure injury.
B) Improving the client's hydration: While hydration is essential for overall skin health, it is not directly related to reducing shearing force on a pressure injury. Hydration can help maintain skin integrity and promote healing but does not directly address the mechanical forces contributing to pressure injuries.
C) Lubricating the area with skin cream: While skin cream can help moisturize and protect the skin, it may not necessarily reduce shearing force on a pressure injury. While lubrication can reduce friction between surfaces, it may not be sufficient to prevent shearing forces that occur during movement or repositioning.
D) Preventing the client from sliding in bed: This is the most appropriate action to decrease shearing force on a stage II pressure injury. Sliding in bed can exacerbate shearing forces on the skin, leading to further damage or delayed healing of the pressure injury. Using devices such as pillows, positioning aids, or specialized mattresses can help prevent the client from sliding and minimize shearing forces on the affected area, promoting healing and preventing further injury.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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