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 C
Explanation
A. Assist a client to eat who has difficulty seeing the foods on the tray.
Assisting a client with eating is a routine task that an AP can perform, especially when the client has difficulty with vision.
B. Provide postmortem care for a client who has died.
Postmortem care involves preparing the body of a deceased client. While it requires sensitivity, it is a task that can be appropriately delegated to assistive personnel.
C. Observe a confused surgical client who has multiple tubes.
Observing a confused client with multiple tubes requires a level of assessment and decision-making that goes beyond the scope of practice for an assistive personnel (AP). This task involves monitoring the client's condition, recognizing changes, and responding appropriately, which should be performed by a licensed nurse.
D. Deliver a client's urine specimen to the laboratory.
Transporting a urine specimen to the laboratory is a task that an assistive personnel can perform, as it does not involve interpretation or assessment of the specimen.
Correct Answer is ["A","B","E"]
Explanation
A. Water heater temperature 54.4°C (130° F):
This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.
B. Electric cords behind furniture:
Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.
C. Bathtub with rails:
Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.
D. Raised toilet seats:
Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.
E. Throw rugs:
Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.
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