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
This response shows that the newly licensed nurse knows the components of the Braden scale, which are sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
Correct Answer is A
Explanation
The nurse should explain the need to have another adult drive the client home following surgery, as this is a safety measure to prevent complications such as bleeding, infection, or injury due to impaired cognition or mobility after anesthesia or sedation. The nurse should ask the client to shower once with an antiseptic soap on either the night before or morning of surgery, not 3 times the day before surgery, as this can reduce the risk of surgical site infection. The nurse should inform the client that they cannot wear makeup during surgery, as this can interfere with the monitoring of skin color and oxygen saturation. The nurse should instruct the client to stop drinking clear liquids at least 2 hours before surgery, not 1 hour before surgery, as this can reduce the risk of aspiration and gastric distension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.