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
An ankle-foot orthotic can help prevent a plantar flexion contracture of the affected extremity in a client who has right-sided paralysis following a cerebrovascular accident. This device can help maintain the foot and ankle in a neutral position and prevent the development of a contracture.
a. A sequential compression device is used to prevent deep vein thrombosis and is not specifically designed to prevent contractures.
b. An abduction splint is used to maintain the hip in a neutral position and is not specifically designed to prevent contractures of the foot and ankle.
d. A continuous passive motion machine is used to promote joint mobility and is not specifically designed to prevent contractures of the foot and ankle.
Correct Answer is C
Explanation
When using a two-wheeled walker, the client should stand with their elbows slightly flexed while holding the walker. This allows for proper posture and support while using the walker.
Option a is incorrect because stooping forward can cause strain on the back and neck.
Option b is incorrect because moving the walker too far ahead can cause instability and increase the risk of falls.
Option d is incorrect because picking up the walker with each step can cause fatigue and decrease the effectiveness of the walker.
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