A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
The area surrounding the insertion site feels warm to the touch.
The infusion rate has stopped but the tubing is not kinked.
There is fluid leaking around the insertion site.
There is no blood return when the tubing is aspirated.
The Correct Answer is A
Choice A rationale
Warmth around the IV insertion site is a classic sign of phlebitis, which is inflammation of the vein. This can be caused by irritation from the IV catheter or the infusing solution.
Choice B rationale
A stopped infusion rate without a kinked tubing could indicate an occlusion or infiltration, but it is not a specific sign of phlebitis.
Choice C rationale
Fluid leaking around the insertion site suggests infiltration or extravasation, where the IV fluid leaks into the surrounding tissue, rather than phlebitis.
Choice D rationale
Lack of blood return when aspirating the tubing could indicate a positional issue or occlusion, but it is not specific to phlebitis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.
Choice B rationale
Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.
Choice C rationale
Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.
Choice D rationale
Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.
Correct Answer is C
Explanation
Choice A rationale
A mesh-like device within the catheter that springs open is characteristic of a stent, not a balloon-tipped catheter used in PTCA. Stents are often used in conjunction with angioplasty to keep the artery open after the balloon has compressed the plaque.
Choice B rationale
While catheters can be used to take pressure measurements, this is not the primary function of the balloon-tipped catheter in PTCA. The main purpose of the balloon-tipped catheter is to compress the plaque against the artery wall to improve blood flow.
Choice C rationale
The balloon-tipped catheter in PTCA is used to compress the plaque against the coronary blood vessel wall. This process, known as balloon angioplasty, helps to widen the artery and improve blood flow to the heart.
Choice D rationale
Cutting away plaque with an embedded blade is a description of atherectomy, not PTCA. Atherectomy involves a different type of catheter designed to remove plaque from the artery wall.
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