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 ["A","B","D","E"]
Explanation
The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much fluid too quickly during a blood transfusion.
c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a different type of transfusion reaction.
Correct Answer is A
Explanation
When providing teaching about health promotion guidelines to a group of young adult male clients, the nurse should include the recommendation to have a dental examination every 6 months. Regular dental examinations can help prevent dental problems and maintain good oral health.
b) A testicular examination is recommended annually, not every 2 years.
c) A tetanus booster is recommended every 10 years, not every 5 years.
d) A herpes zoster immunization is recommended for adults age 60 and older, not age 50.
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