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A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)

Damp dressing

Warmth at insertion site

Streak formation

Throbbing

Erythema

Answer and Explanation

Correct Answer : B,C,D,E

Answer: (B, C, D, E)

Rationale:

A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.

B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.

C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.

D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.

E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.

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Correct Answer is B

Explanation

A. "Gradually decrease the dose once tolerance to the effect is reached." - Gradually decreasing the dose may help mitigate daytime sedation, but it's not the most appropriate initial response. Additionally, it should be done under the guidance of a healthcare provider.

B. "Take most of the daily dose at bedtime." - This response is appropriate because diphenhydramine commonly causes drowsiness, and taking most of the dose at bedtime can help minimize daytime sedation.

C. "Take the medication with meals." - Taking diphenhydramine with meals may reduce the risk of gastrointestinal upset but is unlikely to significantly decrease daytime sedation.

D. "Distribute the doses evenly throughout the day." - This approach may not effectively minimize daytime sedation because diphenhydramine's sedative effects are prolonged and may persist throughout the day if taken at regular intervals. Taking most of the dose at bedtime is a more practical strategy.

A. Check the child's blood pressure. B. Shake the container vigorously. C. Be sure the child has not eaten within the hour. D. Perform mouth care.

Correct Answer is B

Explanation

B. Shake the container vigorously:

This is the correct action. Phenytoin suspension tends to settle over time, leading to non-uniform distribution of the medication in the suspension. Therefore, shaking the container vigorously before administering each dose ensures proper dispersion of the medication and helps maintain consistent drug concentration, thus promoting therapeutic efficacy.

A. Check the child's blood pressure:

Checking the child's blood pressure is not directly related to the administration of phenytoin suspension. Monitoring blood pressure may be indicated in certain clinical situations or with certain medications, but it is not specifically required before administering phenytoin suspension.

C. Be sure the child has not eaten within the hour:

While it's important to consider food-drug interactions with certain medications, such as those affected by food intake, there are no specific dietary restrictions associated with phenytoin suspension administration. Therefore, checking whether the child has eaten within the hour is not a necessary step before administering phenytoin suspension.

D. Perform mouth care:

Performing mouth care is not directly related to the administration of phenytoin suspension. However, oral hygiene is important for overall health, especially in children who may have difficulty performing adequate mouth care independently. While mouth care should be encouraged, it is not specifically required before administering phenytoin suspension.

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A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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