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 D

Explanation

When caring for a client who has a chest tube following thoracic surgery, the nurse can delegate the task of assisting the client to select food choices from the menu to an assistive personnel. This task is within the scope of practice of an assistive personnel and does not require the specialized knowledge or judgment of a nurse.

Option a is incorrect because monitoring the characteristics of the client's chest tube drainage requires specialized knowledge and should not be delegated.

Option b is incorrect because evaluating the client's response to pain medication requires specialized knowledge and should not be delegated.

Option c is incorrect because teaching deep breathing and coughing to the client requires specialized knowledge and should not be delegated.

A. Dangle the client's arm over the edge of the bed. B. Stroke the skin near the vein in an upward direction. C. Instruct the client to ﬂex their arm with the hand open. D. Apply a cool compress to the vein for 10 min.

Correct Answer is A

Explanation

The correct answer is that the nurse should dangle the client's arm over the edge of the bed to help dilate the vein. This technique uses gravity to increase blood ﬂow to the arm and dilate the veins, making it easier to insert a peripheral IV catheter.

Options b, c and d are not eﬀective techniques for dilating a vein for IV insertion. Stroking the skin near the vein in an upward direction, instructing the client to ﬂex their arm with the hand open and applying a cool compress to the vein for 10 min are not eﬀective methods for dilating a vein.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

Correct Answer is A

Explanation

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