A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

Thrombophlebitis

Infiltration

Infection

Extravasation

Answer and Explanation

The Correct Answer is A

Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.

Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.

Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.

Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.

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Correct Answer is D

Explanation

Choice A Reason:

Defamation of character is incorrect. Defamation of character involves making false statements about someone that damage their reputation. This can be in the form of slander (spoken) or libel (written). Applying restraints without proper justification does not fall under defamation of character.

Choice B Reason:

Invasion of privacy is incorrect. Invasion of privacy involves intruding into someone’s personal life without consent. This can include unauthorized access to personal information or spaces. Applying restraints without proper justification is not an invasion of privacy.

Choice C Reason:

Slander is incorrect. Slander is a form of defamation that involves making false spoken statements that damage someone’s reputation. Applying restraints without proper justification does not involve making false statements.

Choice D Reason:

False imprisonment is correct. False imprisonment involves restraining a person without legal justification or their consent. In a healthcare setting, applying restraints without proper justification or following legal and ethical guidelines constitutes false imprisonment and violates the client’s rights.

A. Keep the drainage system below the level of the client’s chest at all times. B. Clamp the chest tube prior to transferring the client to a wheelchair. C. Empty the collection chamber prior to transport. D. Disconnect the chest tube from the drainage system during transport.

Correct Answer is A

Explanation

Choice A Reason:

Keep the drainage system below the level of the client’s chest at all times is correct. This measure ensures that gravity assists in the drainage of air and fluid from the pleural space, preventing backflow into the chest cavity. Keeping the drainage system below chest level maintains the negative pressure needed for effective drainage.

Choice B Reason:

Clamp the chest tube prior to transferring the client to a wheelchair is incorrect. Clamping the chest tube can lead to a buildup of air or fluid in the pleural space, potentially causing a tension pneumothorax. The chest tube should remain unclamped to allow continuous drainage.

Choice C Reason:

Empty the collection chamber prior to transport is incorrect. While it is important to monitor and manage the drainage, emptying the collection chamber is not necessary before transport. The focus should be on maintaining the integrity and function of the drainage system.

Choice D Reason:

Disconnect the chest tube from the drainage system during transport is incorrect. Disconnecting the chest tube can lead to a loss of the negative pressure system, resulting in potential complications such as pneumothorax. The chest tube should remain connected to ensure continuous drainage and maintain the negative pressure.

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A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

Correct Answer is A

Explanation

A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

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A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

The nurse is caring for a newborn requiring a life-saving blood transfusion. The parents are practicing Jehovah’s Witnesses and refuse the transfusion. Who would the nurse consult for assistance in this situation?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which statement would the nurse identify as an indication that the client needs additional education?

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