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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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Place a towel in the sink when cleaning the dentures: Lining the sink with a towel or filling it partially with water provides a cushion to prevent the dentures from breaking if accidentally dropped during cleaning. This is a key safety step in proper denture care.

B. Remove the lower dentures before the upper dentures: Upper dentures should be removed first because they are usually looser and easier to dislodge. Removing the lower dentures first increases the risk of damaging the upper set or causing discomfort to the client.

C. Store the dentures in a dry denture cup on the bedside table after cleaning: Dentures should always be stored in water or a denture-cleaning solution when not in use to prevent warping. Leaving them dry can cause them to crack, lose their shape and may increase contamination risk.

D. Use a circular motion to cleanse the biting surface of the dentures: Denture cleaning requires gentle scrubbing using vertical or back-and-forth strokes rather than circular motions, to effectively remove debris and avoid damaging the prosthetic structure.

A. The client presents to clinic reporting a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well. B. Oriented x 4. Answers questions appropriately, follows simple commands. Heart rate regular, S1 S2 auscultated. No abnormal heart sounds heard. Respiration even and unlabored. Lung sounds clear to auscultation. Abdomen soft, flat, normoactive bowel sounds in all four quadrants. Client states, "appetite is good" and stools are soft and brown. C. Reports voiding without difficulty, clear yellow urine. D. Reports last menstrual period was 3 months ago. E. Skin is warm and moist. Exophthalmos noted, goiter visualized on neck. F. Client's partner reports that the client is irritable and anxious lately.

Correct Answer is ["A","D","E","F"]

Explanation

Rationale:

• 3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and insomnia: These symptoms are consistent with hypermetabolic activity seen in hyperthyroidism, particularly Graves’ disease, and require follow-up and management to prevent complications like thyroid storm.

• Last menstrual period was 3 months ago: Amenorrhea can occur due to hormonal imbalance caused by elevated thyroid hormones. This finding indicates endocrine dysfunction and should be investigated further.

• Skin is warm and moist. Exophthalmos noted, goiter visualized on neck: These are classic physical signs of Graves’ disease, an autoimmune hyperthyroid condition. The exophthalmos (protruding eyes) and goiter (thyroid enlargement) are abnormal and require follow-up.

• Client's partner reports that the client is irritable and anxious lately: Mood changes, such as irritability and anxiety, are common in hyperthyroidism and may affect the client’s quality of life and safety. This finding warrants further psychological and endocrine evaluation.

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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 caring for a client who is unable to perform ADLS and wears dentures. Which of the following actions should the nurse take when providing denture care?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client in a provider's clinic. Exhibits Select the findings that require follow-up.

Correct Answer is ["A","D","E","F"]

Explanation

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