The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?
Warmth and palpable cord along the vein
A raised ecchymotic painful area
Swelling and tenderness at the site
Blanching and coolness of surrounding skin
The Correct Answer is A
A. These are indicative of inflammation within the vein, which is characteristic of phlebitis. Warmth is a common sign of inflammation, and the palpable cord suggests that the vein may be hardened or cord- like due to inflammation and irritation.
B. While this could indicate some form of vascular injury or extravasation, it is not a typical presentation of phlebitis. Phlebitis involves inflammation of the vein, which may cause redness, warmth, and tenderness along the course of the vein, but it typically does not manifest as a raised ecchymotic (bruised) area.
C. Swelling occurs due to inflammation within the vein, and tenderness is often present as a result of the irritation and inflammation. These symptoms are commonly observed in cases of phlebitis but are not specific.
D. These are not typical signs of phlebitis. Blanching (turning white) and coolness of the skin may suggest reduced blood flow to the area, which could occur in cases of ischemia or thrombosis but are not characteristic of phlebitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Experiencing multiple stressors simultaneously can overwhelm an individual's coping resources and make it more difficult to effectively manage stress. Coping with multiple stressors can lead to feelings of being overwhelmed, heightened anxiety, and decreased ability to cope with each stressor individually.
A. Undergoing a biopsy can be a stressful experience due to uncertainty about the results and fear of the procedure itself. However, the level of difficulty in coping with this stressor can vary among individuals depending on factors such as their coping mechanisms, social support, and previous experiences with medical procedures.
B. Relocating to an assisted-living facility can be a significant life transition, involving changes in living arrangements, loss of independence, and adjustment to a new environment. This stressor can be particularly challenging for individuals who have strong attachments to their current living situation or who are facing health-related issues that necessitate the move.
C. Understanding and researching the stressor can sometimes help individuals cope better by providing knowledge and a sense of control. However, this does not necessarily make coping with the stressor easier, especially if the stressor itself is significant or if the individual lacks adequate support or resources to manage it effectively.
Correct Answer is A
Explanation
A. In respiratory alkalosis, the pH is elevated (alkalotic), the PaCO2 (partial pressure of carbon dioxide) is decreased (hypocapnia), and the HCO3 (bicarbonate) level may be within normal limits or slightly decreased due to compensatory mechanisms. In this option, the pH is elevated (7.54), the PaCO2 is decreased (25), and the HCO3 level is within normal limits (24). These findings support respiratory alkalosis.
B. pH 7.50, PaCO2 40, HCO3 28: In this option, the pH is elevated (7.50), the PaCO2 is within normal limits (40), and the HCO3 level is elevated (28). These findings are not consistent with respiratory alkalosis. Instead, they suggest metabolic alkalosis, where both the pH and bicarbonate levels are elevated.
C. pH 7.35, PaCO2 35, HCO3 22: In this option, the pH is within normal limits (7.35), the PaCO2 is within normal limits (35), and the HCO3 level is within normal limits (22). These findings are not consistent with respiratory alkalosis.
D. pH 7.32. PaCO2 48, HCO3 24: In respiratory alkalosis, the pH is elevated (alkalotic), the PaCO2 is decreased (hypocapnia), and the HCO3 level may be within normal limits or slightly decreased due to compensatory mechanisms. In this option, the pH is within normal limits (7.32), the PaCO2 is elevated (48), and the HCO3 level is within normal limits (24). These findings are not consistent with respiratory alkalosis.
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