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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

Airway obstruction is not a common complication of a femoral head fracture or skin traction.

Choice B rationale

Pneumonia can cause shortness of breath but is not the most likely complication in this scenario.

Choice C rationale

Pneumothorax is less likely in this context compared to a fat embolism.

Choice D rationale

Fat embolism is a known complication of fractures, especially long bone fractures like the femoral head. It can cause respiratory distress and dyspnea.

A. Moist skin. B. Blood in the urine. C. Spider angiomas. D. Tarry stools.

Correct Answer is C

Explanation

Choice A rationale

Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.

Choice B rationale

Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.

Choice C rationale

Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.

Choice D rationale

Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

Correct Answer is D

Explanation

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

Correct Answer is C

Explanation

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