A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
Coolness
Drainage
Pallor
Erythema
The Correct Answer is D
A. Coolness at the IV insertion site is not a typical sign of phlebitis. Phlebitis often presents with warmth or increased heat around the vein due to inflammation.
B. Drainage at the IV site might indicate infection or other complications but is not a specific sign of phlebitis. Phlebitis primarily manifests as redness, tenderness, and swelling along the vein.
C. Pallor (pale coloration) at the IV site is not a typical sign of phlebitis. Phlebitis usually presents with redness or erythema due to inflammation.
D. Erythema (redness) at the IV catheter insertion site is a hallmark sign of phlebitis. It indicates inflammation of the vein where the catheter is placed and is a common early sign of phlebitis. Other signs include warmth, tenderness, and swelling along the vein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate the dosage of amoxicillin, the nurse needs to divide the prescribed dose by the available dose and multiply by one tablet. In this case, the prescribed dose is 500 mg and the available dose is 250 mg. Therefore, the nurse should administer:
(500 mg / 250 mg) x 1 tablet = 2 tablets
The nurse should document the administration of amoxicillin in the patient's chart and monitor for any adverse reactions or allergies.
Correct Answer is B
Explanation
A. Position the client on her side:
While placing the client on her side is important, especially if there is a risk of aspiration during the seizure, maintaining the airway takes precedence as the priority action.
B. Maintain the patency of the client's airway:
This is the correct answer. Ensuring the airway is open and unobstructed is the immediate priority during a seizure. This involves positioning the client to prevent airway compromise and potentially using suction if necessary.
C. Identify the poison the client ingested:
While identifying the poison is important for subsequent management, it is not the immediate priority during an active seizure. The focus is on stabilizing and ensuring the client's safety.
D. Measure the client's blood pressure:
Monitoring vital signs, including blood pressure, is an essential aspect of care, but it is not the immediate priority during an active seizure. Airway management takes precedence to prevent complications such as hypoxia.
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