A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Streak formation along the vein

Erythema at the insertion site

Blistering around the insertion site

Warmth at insertion site

Damp dressing over the insertion site

Answer and Explanation

Correct Answer : A,B,D

A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.

B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.

C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.

D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.

E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.

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Correct Answer is B

Explanation

B. Subcutaneous injections are generally administered at a 45° or 90° angle, depending on the amount of subcutaneous tissue present. In obese clients, there is typically more subcutaneous tissue, so inserting the needle at a 90° angle may be necessary to ensure proper medication absorption.

A. A smaller gauge needle (such as 25 or 26 gauge) is usually more appropriate for subcutaneous injections to minimize discomfort and tissue trauma, especially in obese clients where there is more subcutaneous tissue.

C. Massaging the injection site after administering heparin is not recommended. It can cause discomfort, bruising, and potentially alter the absorption rate of the medication. The injection site should be gently

pressed with a dry gauze pad after withdrawal of the needle to help disperse the medication and prevent leakage, but massaging should be avoided.

D. Aspiration is not necessary for subcutaneous injections. It is generally used for intramuscular injections to ensure the needle is not in a blood vessel, which is less of a concern for subcutaneous injections. The injection technique involves pinching the skin and injecting the medication into the subcutaneous tissue without aspirating.

A. 60° B. 45° C. 75° D. 90°

Correct Answer is D

Explanation

D. A 90° angle (perpendicular to the skin surface) is typically used for IM injections into muscles where the needle needs to penetrate deeply into the muscle tissue.

A. 60° angle is commonly used for IM injections in the deltoid muscle or thigh. However, it may not be optimal for the ventrogluteal site, which typically requires a different approach due to its deeper location and muscle structure.

B. A 45° angle is typically used for subcutaneous injections, where the needle is inserted into the fatty layer just below the skin surface.

C. This angle is steeper than 60° and is sometimes used for IM injections into muscles with thicker tissue or larger muscle mass.

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A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Nursing Test Bank

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