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 []

Explanation

Rationale:

Dependent personality disorder: Characterized by excessive need to be taken care of and fear of separation. This does not fit the client’s symptoms of hopelessness, poor hygiene, flat affect, and suicidal thoughts, which are more consistent with major depression.
Schizophrenia: Involves hallucinations, delusions, and disorganized behavior, none of which are reported in this client. The absence of psychosis and the presence of mood-based symptoms suggest a depressive disorder rather than a psychotic disorder.
Major depressive disorder: Fits with the client's expression of hopelessness, withdrawal, poor hygiene, job loss, and suicidal ideation. These are classic symptoms of major depression and require careful monitoring and support.
Dementia: Typically includes memory impairment, disorientation, and decline in cognitive function. The client is coherent, oriented, and presenting with mood rather than cognitive issues, ruling out dementia.
Speak with the client using simple words: While clear communication is always beneficial, there is no indication the client has cognitive impairment requiring simplified language. The priority is emotional support and safety, not communication complexity.
Remain in the room with the client: Ensures the client feels supported and safe, especially in the context of suicidal ideation. Continuous presence also allows for immediate intervention if the client's mental state worsens.
Encourage client to eat slowly: Not relevant to the client’s presentation. There are no issues with appetite, swallowing, or physical illness necessitating this intervention. It does not address the mental health concerns at hand.
Assist the client to identify stressors: Helps promote insight and develop coping mechanisms. Identifying stressors is essential in managing depressive symptoms and planning appropriate therapeutic strategies.
Determine client’s level of disorientation: The client is not exhibiting signs of confusion or disorientation. This action would be more appropriate for cognitive disorders such as dementia or delirium.
Panic attacks: The client reports anxiety but has not described acute panic symptoms like hyperventilation or chest tightness. Monitoring panic attacks is not a priority in this depressive context.
Hallucinations: There is no evidence of perceptual disturbances. The client is not demonstrating psychosis, so monitoring for hallucinations is not indicated.
Wandering at night: More relevant for clients with dementia or delirium. This client is coherent and not at risk of nocturnal wandering.
Suicidal ideation: A key concern due to the client expressing that life is not worth living. This must be monitored continuously for client safety and to guide suicide prevention strategies.
Sleep patterns: Depression commonly affects sleep, leading to insomnia or hypersomnia. Monitoring sleep helps gauge treatment response and overall progress in managing depressive symptoms.

A. Heart rate B. Stool results C. Current medications D. WBC count E. Hemoglobin and hematocrit F. Temperature G. Blood pressure H. Respiratory rate

Correct Answer is ["A","B","C","E","G"]

Explanation

Rationale:

Heart rate: A heart rate of 118/min indicates tachycardia, which may be a compensatory response to hypovolemia or blood loss. Combined with low blood pressure and low hemoglobin/hematocrit, it raises concern for active gastrointestinal bleeding and hemodynamic instability.
Stool results: A positive hemoccult test confirms gastrointestinal bleeding, especially when paired with the client’s report of dark, tarry stools (melena). This requires prompt evaluation and may indicate upper GI bleeding, such as from a peptic ulcer.
Current medications: The client is taking high-dose ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), which can cause or worsen gastric ulcers and bleeding. Continued use should be stopped immediately and replaced with safer alternatives.
WBC count: The WBC count is within the normal range and does not indicate an active infection or inflammatory process at this time. It does not require urgent follow-up compared to other findings.
Hemoglobin and hematocrit: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting blood loss likely due to GI bleeding. These values warrant urgent follow-up and possible transfusion depending on symptoms and stability.
Temperature: The client’s temperature of 37.5°C (99.5°F) is slightly elevated but within normal limits and not a priority concern. There are no signs of infection or fever that require immediate follow-up.
Blood pressure: A BP of 90/50 mm Hg indicates hypotension, which is concerning in the context of GI bleeding and low hemoglobin. This may reflect hypovolemia and requires prompt fluid management and monitoring.
Respiratory rate: A respiratory rate of 18/min is within normal limits and does not indicate respiratory distress. It does not require immediate follow-up in this context.

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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

Correct Answer is []

Explanation

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit Exhibits The nurse is reviewing the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","E","G"]

Explanation

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