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 A

Explanation

A. IV solutions and administration sets should typically be changed every 48 to 72 hours to reduce the risk of contamination and infection. This interval helps prevent the buildup of bacteria in the solution and tubing, which could lead to bloodstream infections (BSIs).

B. Checking the client's IV site every is also important for monitoring for signs of infection, infiltration, or phlebitis. However, every 8 hours is too frequent and unnecessary

C. IV tubing should be changed every 72 hours not every 96 hours. Prolonging the use of IV tubing beyond this timeframe increases the risk of bacterial contamination and infection.

D. Transparent dressings are usually changed every 5 to 7 days, or sooner if they become soiled or compromised.

Correct Answer is ["50"]

Explanation

To calculate the flow rate in gtt/min, the total volume (400 mL) should be divided by the total time in minutes (8 hours x 60 minutes/hour = 480 minutes). This gives the mL/min.

Then, multiply the mL/min by the drop factor (60 gtt/mL) to get the gtt/min. So, the calculation would be (400 mL / 480 min) x 60 gtt/mL = 50 gtt/min.

Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion through a short-peripheral device. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is ["50"]

Explanation

The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:

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