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 C

Explanation

The nurse should assist the client with a bowel cleansing before an intravenous pyelogram. This helps to ensure that the bowel is empty and that the images obtained during the procedure are clear. The other

a. Oral contrast is not typically used for an intravenous pyelogram.

b. Pain in the suprapubic region is not a common side eﬀect of an intravenous pyelogram.

d. Removing metal objects is important for procedures that use magnetic resonance imaging (MRI), but it is not necessary for an intravenous pyelogram.

A. The client's room number B. The client's admitting diagnosis C. The name of the client's next of kin D. The client's telephone number

Correct Answer is D

Explanation

The nurse should plan to use the client's telephone number to confirm their identity. This is because the telephone number is a unique identifier that is directly associated with the client and can be easily verified. By comparing the client's telephone number with the information on the medication administration record or electronic health record, the nurse can ensure that the right medication is given to the right patient.
Explanation:
a) The client's room number is not a reliable method to confirm the client's identity because multiple clients may be assigned to the same room, and there is a possibility of room changes or transfers.
b) The client's admitting diagnosis is not a suitable method to confirm identity as it does not provide specific information about the individual patient.
c) The name of the client's next of kin is not a reliable method to confirm the client's identity as it refers to a family member or emergency contact, not the client themselves. Additionally, next of kin information may not always be up to date or readily available.

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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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