A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as grade level 1. Which of the following assessment findings correlates with a grade level of 1?
Purulent drainage at the intravenous site access site.
Redness at the intravenous access site with pain.
Red streaks on the affected extremity.
Palpable venous cord in the affected extremity.
The Correct Answer is B
Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.
Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.
Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.
Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Abdominal distention can be a sign of delayed return of peristalsis or ileus, especially when accompanied by other symptoms such as nausea, vomiting, or lack of bowel movement. It is not typically a sign that peristalsis is returning.
Choice B reason:
A request for a cup of tea and some toast may indicate that the client is feeling better and is hungry, which can be a good sign. However, it is not a definitive clinical indicator of the return of peristalsis. The desire to eat does not necessarily mean that the digestive system is ready to process food.
Choice C reason:
Hypoactive bowel sounds in two quadrants may indicate that peristalsis is present but weak. While this could be a sign that peristalsis is starting to return, it is not as strong an indicator as the passage of flatus or stool.
Choice D reason:
The passage of flatus is a clear sign that peristalsis is returning. It indicates that gas is moving through the intestines, which is a function of peristalsis. This is often one of the first signs that the gastrointestinal system is recovering after surgery.
Correct Answer is B
Explanation
Choice A reason:
Resuming a regular diet immediately after the test may not always be recommended. Depending on the individual's condition and the specific instructions from the healthcare provider, there may be dietary restrictions before or after the procedure.
Choice B reason:
Encouraging fluid intake after the procedure is important because it helps to flush out the contrast dye used during the IVP. Adequate hydration can aid in the elimination of the dye and reduce the risk of kidney damage, especially in individuals with pre-existing kidney conditions.
Choice C reason:
This statement is incorrect. An IVP does not use high-frequency sound waves; it involves taking X-ray images of the urinary tract after a contrast dye is injected into a vein. The dye outlines the kidneys, ureters, and bladder on the X-ray images.
Choice D reason:
The presence of red blood cells in the urinalysis does not typically result in the cancellation of an IVP. However, certain conditions, such as an allergy to the contrast dye or severe kidney impairment, may contraindicate the use of an IVP.
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