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 D
Explanation
Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.
Correct Answer is B
Explanation
The client should press the inner corner of their eye after inserting the drops to prevent systemic absorption and reduce side effects. The client should raise their eyelid up while looking up (not down) to insert the drops.
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