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 B
Explanation
The correct answer is **b. A room containing personal belongings.**
Choice A rationale:
A room without a window would not be a therapeutic environment for a cognitively impaired client. Lack of natural light and connection to the outside world can be disorienting and distressing for these patients.
Choice B rationale:
A room containing personal belongings is the most therapeutic environment for a cognitively impaired client. Familiar objects and surroundings can help provide a sense of comfort, security, and orientation. This can reduce agitation and confusion, which are common issues for cognitively impaired patients.
Choice C rationale:
A room adjacent to the nursing station may not be the most therapeutic environment. While proximity to staff can be beneficial, the increased noise and activity level near the nursing station could be overstimulating and disruptive for a cognitively impaired client.
Choice D rationale:
A room with dim lighting is not ideal for a cognitively impaired client. Adequate lighting is important to help these patients maintain orientation and avoid falls or other safety issues. Dim lighting can contribute to confusion and disorientation.
Correct Answer is A
Explanation
Explanation: Evisceration is a surgical emergency that occurs when the abdominal contents protrude through the incision site. The nurse should instruct the client to lie supine with his knees flexed to reduce tension on the wound and prevent further damage.
The nurse should also cover the wound with a moist sterile dressing and notify the surgeon immediately. Positioning the client in semi-Fowler's position, covering the wound with a dry sterile dressing, or covering the wound with a transparent dressing are not appropriate actions for evisceration.
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