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 B
Explanation
A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.
C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.
Correct Answer is B
Explanation
A. Concurrent treatment for GERD (gastroesophageal reflux disease) is not typically a contraindication for hormone replacement therapy. However, it's essential to assess the specific details of the client's medical history and medications to ensure safe use.
B. A history of breast cancer is a significant contraindication for hormone replacement therapy. Estrogen, a component of many HRT regimens, can stimulate the growth of certain types of breast cancer. Therefore, HRT is generally avoided in individuals with a history of breast cancer.
C. A history of dermatitis is not typically a contraindication for hormone replacement therapy. However, individual circumstances should be considered, and any concerns related to skin conditions should be discussed with the healthcare provider.
D. Multiple hospitalizations for COPD (chronic obstructive pulmonary disease) may not be a direct contraindication for hormone replacement therapy, but the overall health status and individual medical history should be carefully considered before initiating HRT.
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