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

Answer and Explanation

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.

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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.

A. Encourage the client to try ways to stay awake during the day. B. Substitute physical therapy for one of the client's usual nap times. C. Ask the physician to order a sleeping pill for the client to take at night. D. Do nothing, as no action is necessary in this situation.

Correct Answer is D

Explanation

D. It is important to recognize and respect the client's natural sleep patterns, especially considering their age and current health status. Napping during the day can be a normal and beneficial behavior for older adults, helping to replenish energy levels and promote overall well-being. As long as the client's napping does not interfere with their ability to sleep at night or their daily activities, no intervention may be necessary.
A. Encouraging the client to stay awake during the day may not be appropriate, especially considering the client's age and natural sleep patterns. Older adults often experience changes in their sleep-wake cycle, including more frequent napping during the day.
B. Physical activity is important for maintaining mobility and overall health but substituting physical therapy for one of the client's usual nap times may not be feasible or beneficial. The client's need for rest and sleep should be respected, especially if they are experiencing fatigue or illness.
C. Prescribing a sleeping pill for the client may not be appropriate, especially if they are already napping during the day. Sleep medications can have side effects, including drowsiness, confusion, and increased risk of falls, particularly in older adults.

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The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

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