A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.
Which of the following actions should the nurse plan to take?
Apply a pressure dressing at the IV site.
Place a warm, moist compress on the site.
Express drainage from the IV site and send it to be cultured.
Insert a new IV catheter distal to the discontinued IV site.
The Correct Answer is B
Choice A rationale:
Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.
Choice B rationale:
Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.
Choice C rationale:
Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.
Choice D rationale:
Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Distributive justice refers to the fair distribution of resources, benefits, and burdens in society. Ensuring that a homeless client receives preventive medical care exemplifies distributive justice as it promotes equal access to healthcare resources for all individuals, regardless of their housing situation.
Choice B rationale:
Being honest with the parents of a child about the need to report suspected abuse is an example of veracity, which is the duty to tell the truth. While honesty is important, it does not directly relate to distributive justice.
Choice C rationale:
Accepting the decision of an older adult client to live alone in her home respects the client's autonomy and independence but does not specifically demonstrate distributive justice.
Choice D rationale:
Keeping a promise to visit with a housebound client is an example of fidelity, the duty to fulfill promises. While it is ethically important, it does not exemplify distributive justice, which pertains to fair resource allocation.
Correct Answer is D
Explanation
Choice A rationale:
Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.
Choice B rationale:
Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.
Choice C rationale:
Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.
Choice D rationale:
Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.
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