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. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.

A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.

C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.

D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.

A. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. B. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. C. Find the center of the anterior aspect of the thigh. D. Locate the center of the arm between the elbow and the shoulder.

Correct Answer is B

Explanation

B. This method is recommended because the deltoid muscle is a large, rounded, triangular muscle that covers the shoulder joint.

A. This description is for locating the vastus lateralis muscle, which is commonly used for intramuscular injections in infants and young children, not adults.

C. This technique is used for locating the rectus femoris muscle, another site for intramuscular injections in infants and young children, not adults.

D. This location is too low, which could miss the muscle tissue and reduce the effectiveness of the vaccine.

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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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