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","D","E"]

Explanation

Rationale:

A. Reinforce client teaching about walking with crutches: Teaching or reinforcing client education is a nursing responsibility and should not be delegated to assistive personnel. It requires assessment, evaluation, and knowledge of the client's learning needs and physical limitations.

B. Plan care for a client who has dysphagia: Care planning involves critical thinking and individualized assessment, which fall under the registered nurse’s scope of practice. Dysphagia management also requires knowledge of aspiration risk and appropriate interventions.

C. Transfer a client who is receiving radiation therapy to radiology: Transferring stable clients to departments such as radiology is within the scope of assistive personnel, as long as the client does not require specialized monitoring or assessment during the transfer.

D. Record urine output for a client who has a suprapubic catheter: Measuring and documenting urinary output is a routine task that assistive personnel can perform. The catheter type does not affect the ability to carry out this basic observation.

E. Measure vital signs for a client who requires contact precautions: Assistive personnel are trained to take vital signs and follow isolation protocols. Measuring vital signs under contact precautions is appropriate as long as proper PPE and hygiene practices are followed.

A. Deep palpation B. Light palpation C. Auscultation D. Inspection

Correct Answer is D,C,B,A

Explanation

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is D,C,B,A

Explanation

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