A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
Coolness of the client's left forearm
Pallor of the client's left forearm
Erythema along the path of the vein
Pitting edema at the insertion site
The Correct Answer is C
The rationale for this answer is that phlebitis is inflammation of a vein caused by mechanical, chemical, or bacterial irritation from an IV catheter or fluid. It manifests as redness, warmth, tenderness, and swelling along the path of the vein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Recording output for a client who has multiple drains and tubes is a task that can be delegated to an AP, as it does not require nursing judgment or assessment skills. Reinserting an NG tube, teaching a family member how to change a dressing, and suctioning a tracheostomy are tasks that require nursing judgment, assessment skills, and specialized knowledge, and therefore cannot be delegated to an AP.
Correct Answer is A
Explanation
The nurse should use a separate, sterile swab for each stroke when cleaning the wound to prevent cross-contamination and infection. The nurse should also clean from the least contaminated area (the incision) to the most contaminated area (the drain site). Cutting a 4x4 piece of gauze to place around the drain site may cause loose fibers to enter the wound and increase the risk of infection. The nurse should wear sterile gloves when cleaning the wound, not just clean gloves.
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