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 D

Explanation

Rationale:

A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.

B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.

C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.

D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.

A. "Use sunglasses if your eyes are sensitive to light." B. "Continue eating foods with protein." C. "Remain on bedrest for 3 to 5 days following discharge." D. "You need to support your neck when coughing or moving." E. "You will no longer need to take any medications for your thyroid now that you have had surgery."

Correct Answer is ["A","B","D"]

Explanation

Rationale:

• "Use sunglasses if your eyes are sensitive to light." Exophthalmos from Graves' disease can persist even after thyroidectomy. Sunglasses help reduce photophobia and protect protruding eyes from dryness and injury.

• "Continue eating foods with protein." Protein is essential for wound healing and energy. Postoperative hypermetabolic states can also increase protein needs, so adequate intake supports recovery.

• "You need to support your neck when coughing or moving." Neck support prevents strain on the surgical site and reduces the risk of wound dehiscence or hematoma formation during activities that increase intrathoracic pressure.

• "Remain on bedrest for 3 to 5 days following discharge." Prolonged bedrest is not recommended post-thyroidectomy. Early ambulation reduces risk of complications such as pneumonia and deep vein thrombosis and supports normal recovery.

• "You will no longer need to take any medications for your thyroid now that you have had surgery." Total or subtotal thyroidectomy often results in hypothyroidism, requiring lifelong thyroid hormone replacement (e.g., levothyroxine). Medication needs depend on the amount of thyroid tissue removed.

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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 is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is D

Explanation

The nurse has reviewed the Vital Signs at 1000. Exhibits Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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