A nurse is collecting data about the fluid status of four patients.
Which patient should the nurse identify as being at risk for fluid volume deficit?

Choice B rationale:

Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.

Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)

Infection

Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)

Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.

Choice A rationale:

Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.

Choice C rationale:

Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.

Choice D rationale:

Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.

The correct answer is Choice A: Refer questions to the nursing supervisor.

Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.

Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.

Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.

Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.