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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I'll be glad when I can stop taking this medicine.": This statement indicates a misunderstanding about phenytoin therapy. Phenytoin is typically a long-term medication used to prevent seizures, and it is not typically discontinued unless under the guidance of a healthcare provider. The nurse should clarify that stopping the medication abruptly can lead to rebound seizures and should emphasize the importance of continuing the medication as prescribed.
B. "I have made an appointment to see my dentist next week.": This statement indicates appropriate understanding, as regular dental check-ups are important for individuals taking phenytoin due to the medication's potential side effect of gingival hyperplasia.
C. "I know that I cannot switch brands of this medication.": This statement demonstrates understanding, as different brands of phenytoin can have variations in bioavailability, which can affect seizure control. It is important for clients to remain consistent with the same brand or formulation unless directed otherwise by their healthcare provider.
D. "I will notify my doctor before taking any other medications.": This statement indicates understanding of the potential for drug interactions with phenytoin, as it is a hepatic enzyme inducer and can affect the metabolism of other medications. Clients should always consult their healthcare provider before taking any new medications or supplements to ensure compatibility with phenytoin therapy.
Correct Answer is ["A","D","E"]
Explanation
Tardive dyskinesia (TD) is a potential adverse effect associated with long-term use of antipsychotic medications like haloperidol. It manifests as involuntary, repetitive movements, primarily involving the face, mouth, and tongue. The nurse should suspect tardive dyskinesia when observing the following manifestations:
A. Involuntary pelvic rocking and hip thrusting movements: These movements are characteristic of tardive dyskinesia and indicate abnormal involuntary motor activity.
B. Urinary retention and constipation: These are not typical manifestations of tardive dyskinesia. Urinary retention and constipation can be side effects of anticholinergic medications but are not associated with tardive dyskinesia.
C. Fine hand tremors and pill rolling: These manifestations are more characteristic of parkinsonism, which can be a side effect of antipsychotic medications but is distinct from tardive dyskinesia.
D. Tongue thrusting and lip smacking: These are classic manifestations of tardive dyskinesia and indicate abnormal involuntary movements of the tongue and lips.
E. Facial grimacing and eye blinking: These are also common manifestations of tardive dyskinesia, involving involuntary movements of the face, including grimacing and blinking of the eyes.
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