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?

Erythema along the path of the vein

Coolness of the client's left forearm

Pallor of the client's left forearm

Pitting edema at the insertion site

Answer and Explanation

The Correct Answer is A

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

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Correct Answer is B

Explanation

When planning an educational conference about informed consent, the nurse should include information about the potential risks of the procedure. Informed consent is a process in which the client is provided with information about a medical procedure or treatment, including its potential risks and benefits, so that they can make an informed decision about whether to proceed.

Option a is incorrect because after signing the informed consent, the client still has the right to refuse the procedure.

Option c is incorrect because it is not the nurse's responsibility to explain the procedure when obtaining informed consent; this is typically done by the healthcare provider performing the procedure.

Option d is incorrect because a nursing student cannot witness an informed consent; only a licensed healthcare professional can do so.

A. Place the base of a vibrating tuning fork on the top of the client's head. B. Count how many seconds a client can hear a tuning fork after it has been struck. C. Place the base of a vibrating tuning fork on the client's mastoid process. D. Move a vibrating tuning fork in front of the client's ear canals one after the other.

Correct Answer is A

Explanation

The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².

Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.

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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?

Nursing Test Bank

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