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. Cleanse the most contaminated wounds first: Wound care should begin with the cleanest area and progress to the most contaminated to reduce the risk of cross-contamination. Starting with the dirtiest wounds may spread infection to cleaner sites.

B. Use hydrogen peroxide for wound cleaning: Hydrogen peroxide can damage healthy tissue and delay healing. It is generally not recommended for burn wound care due to its cytotoxic effects on granulating tissue.

C. Perform dressing changes every other day: Dressing frequency depends on the type of burn, wound condition, and healthcare provider's orders. Some burn wounds require daily or even more frequent changes to prevent infection and promote healing.

D. Apply dressings with sterile gloves: Sterile technique is critical in burn care to prevent infection. Using sterile gloves during dressing application ensures the wound is protected from external contaminants during a vulnerable healing phase.

A. "We've seen steady improvement in other clients who are depressed." B. "Tell me what you know about depression," C. "No one really knows the answer to that question." D. "The important thing is that he gets better, not how long it takes."

Correct Answer is B

Explanation

Rationale:

A. "We've seen steady improvement in other clients who are depressed.": While this may sound reassuring, it provides generalized information that may create unrealistic expectations. It does not address the partner’s specific concerns or open up a dialogue for emotional support or understanding.

B. "Tell me what you know about depression,": This response encourages open communication and assesses the partner's understanding of the condition. It allows the nurse to provide accurate, individualized information and emotional support based on what the partner already knows or believes.

C. "No one really knows the answer to that question.": Though factually true, this statement may seem dismissive or lacking empathy. It does not invite discussion or support the emotional needs of the partner, who is likely feeling uncertain or overwhelmed.

D. "The important thing is that he gets better, not how long it takes.": This response minimizes the partner’s valid concern about recovery time. It may come across as invalidating and does not provide helpful or therapeutic communication.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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