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 D
Explanation
A. "I will keep my walker at the end of my bed":
While keeping the walker at the end of the bed may be convenient, it is not a safety measure in itself. It's important for the client to use the walker as needed for support and stability, especially during ambulation.
B. "I will place an area rug at the entry of my bathroom":
Placing area rugs can be a fall hazard, as they may cause tripping. It is generally recommended to have non-slip surfaces, especially in areas prone to moisture like the bathroom.
C. "I will keep the fluorescent ceiling light on in my room at night":
While having adequate lighting is important for preventing falls, leaving a fluorescent ceiling light on all night may not be necessary. Using night lights or low-intensity lighting may be more appropriate to prevent disruption of sleep.
D. "I will place a bath seat in my shower to use when I bathe":
This is the correct statement. Using a bath seat in the shower provides stability and reduces the risk of slipping and falling while bathing. It is a proactive measure to enhance safety in the bathroom.
Correct Answer is A
Explanation
A. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.
Incorrect options:
B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.
C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.
D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.
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