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 ["B","C"]

Explanation

Choice A rationale

Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.

Choice B rationale

Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.

Choice C rationale

Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.

Choice D rationale

Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.

Choice E rationale

Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.

A. A client whose daily caloric intake is 25% fat. B. A client who has diabetes mellitus. C. A client who consumes two 12-ounce (0.35-L) alcoholic beverages daily. D. A client who has hypothyroidism.

Correct Answer is B

Explanation

Choice A rationale

A daily caloric intake of 25% fat is within the recommended range and does not significantly increase the risk for peripheral arterial disease (PAD).

Choice B rationale

Diabetes mellitus is a significant risk factor for PAD. High blood sugar levels can damage blood vessels and lead to poor circulation.

Choice C rationale

Consuming two 12-ounce alcoholic beverages daily can contribute to other health issues but is not a primary risk factor for PAD.

Choice D rationale

Hypothyroidism is not directly linked to an increased risk of PAD. It can cause other cardiovascular issues but not specifically PAD.

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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 assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

Correct Answer is B

Explanation

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?

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