A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
Cool skin
Numbness
Edema
Pallor
The Correct Answer is C
A. Cool skin: Cool skin is not typically associated with thrombophlebitis. It is more common with arterial issues rather than venous problems.
B. Numbness: Numbness is generally a sign of nerve involvement or arterial occlusion, not a classic finding of thrombophlebitis, which primarily affects veins.
C. Edema: Edema is a common finding with thrombophlebitis due to venous inflammation and obstruction of blood flow, which leads to fluid accumulation in the affected limb.
D. Pallor: Pallor is more commonly associated with arterial insufficiency rather than venous issues like thrombophlebitis. Thrombophlebitis often presents with redness and warmth instead of pallor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain a blood sample. While obtaining a blood sample to check cardiac enzyme levels is important for diagnosing myocardial injury, it is not the priority over oxygen therapy, given the client’s shortness of breath and cyanosis.
B. Insert the IV catheter. IV access is important for administering fluids and medications, but it is not the first priority in this scenario where the client is experiencing respiratory distress.
C. Initiate oxygen therapy. The client shows signs of hypoxia (shortness of breath and cyanosis), and oxygen is crucial for stabilizing oxygen levels and preventing further deterioration of cardiac and respiratory function.
D. Attach the leads for a 12-lead ECG. Attaching the leads for an ECG is essential to evaluate the client's cardiac status, but it is not the most urgent action in the presence of cyanosis and respiratory distress.
Correct Answer is ["94"]
Explanation
To calculate the rate, divide the total volume to be infused by the time (in hours).
Rate =750 mL ÷ 8 hr
= 93.75 mL/hr
Rounded to the nearest whole number: 94 mL/hr.
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