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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.

B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.

C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.

D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.

A. A 15-year old client who has acne B. A client who has a menstrual cycle every 14 days C. A client who has a blood pressure of 140/90 mm Hg D. A client who has a hematocrit of 39%

Correct Answer is C

Explanation

A. A 15-year-old client who has acne:

Acne alone is not a contraindication to oral contraceptives. In fact, oral contraceptives can sometimes be prescribed to help manage acne.

B. A client who has a menstrual cycle every 14 days:

Having a menstrual cycle every 14 days may indicate an irregular cycle, but it's not a direct contraindication to oral contraceptives. However, the cause of the frequent cycles might need evaluation before starting oral contraceptives.

C. A client who has a blood pressure of 140/90 mm Hg:

Elevated blood pressure (140/90 mm Hg or higher) is a contraindication to oral contraceptives. It increases the risk of complications such as stroke, heart attack, or other cardiovascular issues.

D. A client who has a hematocrit of 39%:

A hematocrit level of 39% is within the normal range and is not a contraindication to oral contraceptives.

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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?

Nursing Test Bank

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