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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The ropes being in the center of the wheel grooves is correct and ensures proper traction.
Choice B rationale
The ropes being securely attached to the pins is correct and necessary for effective traction.
Choice C rationale
The weights being equal on each side is correct and ensures balanced traction.
Choice D rationale
The weights resting against the foot of the bed is incorrect and can interfere with the effectiveness of the traction. .
Correct Answer is A
Explanation
Choice A rationale
The weights from the traction device should only be removed if the client develops a life- threatening situation. This is to ensure the client’s immediate safety and address the critical condition.
Choice B rationale
The client should not have the weights removed for repositioning in the bed. Proper techniques should be used to reposition the client without removing the weights to maintain the effectiveness of the traction.
Choice C rationale
Complaints of pain should be addressed by assessing the cause and providing appropriate pain management, but the weights should not be removed as it can compromise the traction.
Choice D rationale
The weights should not be removed for an x-ray. The traction can be maintained during imaging procedures to ensure continuous treatment.
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