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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Age alone is not a reliable or unique identifier. Many clients can share the same age, and this information does not sufficiently confirm an individual’s identity. Using age alone could lead to errors, as it lacks specificity.
B.Room numbers are not reliable for client identification because clients may be moved to different rooms or share rooms with others. Using a room number alone could easily lead to a medication error, as it does not confirm the client’s personal identity.
C.Using a photograph is an acceptable form of client identification, especially in settings where clients may not be able to verbally confirm their identity (e.g., clients with dementia). Photographs, when available, are typically included in the client’s medical records and can help ensure correct patient identification to prevent medication errors.
D.Bed numbers, similar to room numbers, are not unique to an individual and may change or be shared in multi-bed rooms. Relying on a bed number could result in giving medication to the wrong client, which is a significant risk to client safety.
Correct Answer is B
Explanation
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client's prior coping mechanisms. This will help the nurse to understand how the client has coped with difficult situations in the past and to develop a plan of care that is tailored to the client's individual needs and preferences.
Options a, c, and d are also important interventions, but they are not the priority. Helping the client to find a local support group, developing a list of goals with the client, and teaching the client to use progressive relaxation techniques can all be helpful in supporting the client's emotional well-being, but they should be implemented after the nurse has assessed the client's coping mechanisms and developed a plan of care.
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