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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:

Tennis may not be the best recommendation for someone with low back pain. The sport requires quick lateral movements, sudden stops, and starts, as well as repetitive twisting motions that can exacerbate back pain. While it provides good general exercise, the high-impact nature of tennis and the strain it puts on the back could potentially worsen the client's condition.

Choice B reason:

Canoeing involves repetitive rowing actions that can strain the lower back, especially if the individual does not use proper form. The seated position in a canoe may also put additional pressure on the lower back. Therefore, it might not be the most suitable activity for someone experiencing low back pain.

Choice C reason:

Rowing, similar to canoeing, can place stress on the lower back due to the repetitive motion and the need for strong engagement of the core muscles. If not performed with proper technique, rowing could lead to increased back pain and is not typically recommended for those with existing low back issues.

Choice D reason:

Swimming is often recommended for individuals with low back pain because it is a low-impact exercise that does not put additional stress on the spine. The buoyancy of the water supports the body, reducing the load on the back while allowing for a full range of motion. Swimming can help strengthen the back muscles and improve flexibility, making it a suitable activity for managing low back pain.

A. Hay fever allergy B. Anaphylaxis C. Transplant rejection D. Bacterial phagocytosis

Correct Answer is C

Explanation

Choice A reason:
Hay fever allergy, also known as allergic rhinitis, is primarily associated with the action of Immunoglobulin E (IgE) antibodies and not directly with T-cells. T-cells can contribute to the regulation of the immune response in allergies, but IgE is the main immunoglobulin involved in the typical symptoms of hay fever.

Choice B reason:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that involves the release of large amounts of histamine and other chemicals from mast cells and basophils, often triggered by IgE antibodies. While T-cells can play a role in the sensitization phase of allergy, anaphylaxis itself is not directly caused by T-cells.

Choice C reason:
Transplant rejection is a process in which T-cells play a central role. When a transplant recipient's immune system recognizes the donated organ as foreign, T-cells can mediate the rejection by attacking the transplanted tissue, leading to its failure.

Choice D reason:
Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. T-cells are involved in the adaptive immune response and can activate phagocytes, but they do not directly perform phagocytosis.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

Correct Answer is D

Explanation

A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect?

A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates a rotator cuff injury?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?

A nurse is assessing a client who has a rotator cuff injury. Which of the following findings should the nurse expect?