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 A

Explanation

Rationale:

A. Home telephone number: A home telephone number is an acceptable second client identifier under The Joint Commission's guidelines, as it is specific to the individual and can help prevent medication errors when used alongside another unique identifier.

B. Medical diagnosis: A medical diagnosis is not a unique identifier and may be shared by multiple clients in the same facility. It does not provide adequate confirmation of a client's individual identity.

C. Date of admission: Admission dates are not unique and may be the same for several clients. This information is insufficient as a reliable identifier for ensuring safe medication administration.

D. Facility room number: Room numbers can change during hospitalization and are not considered safe identifiers. Clients may be transferred, making room number an unreliable and non-permanent method of identification.

A. Arterial blood gases B. Blood urea nitrogen C. Prothrombin time D. Thyroid stimulating hormone

Correct Answer is B

Explanation

Rationale:

A. Arterial blood gases: While ABGs assess respiratory and metabolic balance, they are not routinely monitored for clients on furosemide. This test is more relevant for clients with severe respiratory or acid-base disorders, not as a direct indicator of diuretic therapy effects.

B. Blood urea nitrogen: Furosemide is a loop diuretic that can affect kidney function by reducing circulating blood volume. Monitoring BUN helps assess renal perfusion and detect early signs of dehydration or nephrotoxicity associated with diuretic use.

C. Prothrombin time: PT evaluates coagulation status, typically in clients taking anticoagulants like warfarin. Furosemide does not affect clotting pathways, so PT monitoring is unnecessary in this context unless the client is on anticoagulants for another condition.

D. Thyroid stimulating hormone: TSH measures thyroid function but is not influenced by furosemide. There is no established link between furosemide and thyroid activity that would necessitate routine TSH monitoring for clients taking this medication.

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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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