A nurse is monitoring a client following the insertion of a peripheral intravenous catheter. Which of the following findings should indicate to the nurse that the client is experiencing phlebitis at the insertion site?

Leakage of IV fluid

Blood leakage

Red streak

Purulent drainage

Answer and Explanation

The Correct Answer is C

Rationale:

A. Leakage of IV fluid: Leakage of IV fluid at the insertion site suggests infiltration, not phlebitis. In infiltration, fluid escapes into surrounding tissues, leading to swelling and coolness, but not inflammation of the vein itself.

B. Blood leakage: Blood leakage is usually related to poor catheter stabilization or improper insertion, not phlebitis. It does not indicate inflammation or irritation of the vein wall, which are hallmark signs of phlebitis.

C. Red streak: A red streak following the path of the vein is a classic sign of phlebitis. It indicates inflammation of the vein wall and is often accompanied by pain, warmth, and swelling along the vein.

D. Purulent drainage: Purulent drainage is a sign of infection rather than phlebitis. While phlebitis can lead to infection if untreated, purulent drainage points to a more serious complication involving bacterial growth.

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Correct Answer is C

Explanation

Rationale:

A. Wipe from the outer to the inner canthus after administering the drops: The correct technique is to wipe from the inner to the outer canthus to avoid introducing pathogens into the lacrimal system. Wiping in the wrong direction increases the risk of eye infections.

B. Position the child side-lying on the bed before administering the drops: Eye drops should be administered with the child in a supine or slightly reclined position. Side-lying positioning is more appropriate for ear drops and does not allow proper exposure of the conjunctival sac.

C. Apply pressure to the lacrimal punctum after administering the drops: Pressing the lacrimal punctum (inner corner of the eye) helps prevent systemic absorption of the medication by occluding the tear duct. This increases local efficacy and reduces the risk of systemic side effects, which is especially important in children.

D. Flush the eye with formal saline solution before administering the drops: Flushing with formal saline is unnecessary unless there is debris or discharge. Routine eye drop administration does not require pre-flushing..

A. "I will place a night light in the hallway near the bathroom." B. "I will use a standard height toilet seat." C. "I will set my water heater to 145 degrees Fahrenheit." D. "I will cover extension cords with throw rugs.”

Correct Answer is A

Explanation

Rationale:

A. "I will place a night light in the hallway near the bathroom.": Installing night lights in commonly used paths, such as the hallway to the bathroom, helps prevent falls by improving visibility during nighttime trips, which is especially important for older adults with limited vision or balance.

B. "I will use a standard height toilet seat.": Standard height toilet seats can make sitting and standing more difficult for older adults. Raised toilet seats are safer and reduce the risk of falls by minimizing the effort required to use the toilet.

C. "I will set my water heater to 145 degrees Fahrenheit.": This temperature is too high and increases the risk of scald injuries. Water heaters should be set to no more than 120°F to protect older adults from accidental burns, as their skin is often thinner and more sensitive.

D. "I will cover extension cords with throw rugs.": Covering cords with rugs creates a tripping hazard. Extension cords should be secured against walls or removed altogether to reduce fall risk, especially in homes with elderly residents.

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A nurse is monitoring a client following the insertion of a peripheral intravenous catheter. Which of the following findings should indicate to the nurse that the client is experiencing phlebitis at the insertion site?

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