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 ["A","B","C","E"]
Explanation
A. Placing the bedside table within the client's reach helps to minimize the need for the older adult to reach or stretch, reducing the risk of falls.
B. Keeping the bed at a comfortable working height makes it easier for the older adult to get in and out of bed safely.
C. Keeping a night light on in the client's room and bathroom helps improve visibility during the night, reducing the risk of tripping or falling.
D. Administering a sedative at bedtime is generally not recommended as a preventive measure for falls. Sedatives can increase the risk of drowsiness and impaired balance, contributing to falls.
E. Locking the wheels on beds and wheelchairs during transfers helps ensure stability and prevents the equipment from moving unexpectedly, reducing the risk of falls during transfers.
Correct Answer is D
Explanation
A. "Unlike an x-ray, the MRI allows you to move around a bit":
This statement is not accurate. During an MRI, it is important for the client to remain as still as possible to obtain clear images. Movement can result in blurred images.
B. "Your exposure to radiation will be minimal":
This statement is not applicable to MRI, as MRI does not use ionizing radiation. It uses a strong magnetic field and radio waves to generate images, making it different from x-rays in terms of radiation exposure.
C. "You will not be able to talk to the technician during the procedure":
While it is essential for the client to remain still during an MRI, communication with the technician is generally possible through an intercom system. The client may be given instructions and reassurance during the procedure.
D. "You'll have to remove metal objects such as watches and body jewelry":
This is the correct statement. Metal objects can interfere with the magnetic field used in MRI and can pose a safety risk. Therefore, clients are required to remove any metal objects before undergoing an MRI.
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