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 ["B","D"]
Explanation
B. Liquid medications are generally preferred for administration through a feeding tube, as they do not require crushing or dissolving and can be easily administered. Using liquid medications reduces the risk of tube occlusion and ensures accurate dosing. Therefore, this procedure is appropriate for medications available in liquid form.
D. Flushing the tube before medication administration helps ensure patency and clears any residual feeding formula or medication from the tube. This step is essential to prevent clogging of the tube and ensure that the medication reaches the stomach or intestines. Therefore, flushing the tube with water or saline before medication administration is a standard procedure.
A. Crushing tablets and mixing them with water or saline can help ensure that the medication is in a form that can be administered through the gastrostomy tube. However, not all tablets are suitable for crushing, as some medications may have special formulations or coatings that should not be crushed.
Therefore, this procedure is appropriate for medications that are safe to crush and administer via a feeding tube.
C. Mixing medications can potentially alter their effectiveness or stability, so it is essential to follow guidelines and recommendations for medication administration through feeding tubes.
E. Adding medications directly to the tube feeding formula may be appropriate for certain medications that are compatible with the formula and do not require separate administration. However, not all medications can be safely mixed with feeding formula, as some medications may interact with the formula components or become less effective.
Correct Answer is D
Explanation
D. This is the most appropriate technique for evaluating the success of teaching a client a psychomotor skill. A return demonstration involves the client independently performing the skill they have been taught while the nurse observes. This allows the nurse to assess the client's ability to execute the skill correctly, including aspects such as technique, coordination, and safety precautions. Additionally, the nurse can provide immediate feedback and correction if necessary, enhancing the client's learning experience.
A. While answering oral questions can assess the client's understanding of theoretical or conceptual knowledge, it may not effectively evaluate their ability to perform a psychomotor skill. Psychomotor skills involve physical actions and coordination, which cannot be adequately assessed through verbal responses alone.
B. Participating in a discussion group can facilitate sharing of experiences and perspectives among clients, but it may not be the most effective method for evaluating the client's ability to perform a psychomotor skill. Discussion groups are more suitable for exploring attitudes, beliefs, and understanding of concepts rather than assessing physical skills.
C. Written tests typically assess cognitive understanding and retention of information rather than the ability to perform psychomotor skills. While written tests can evaluate knowledge about the steps involved in a skill, they do not directly assess the client's ability to execute the skill itself.
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