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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason:
While the white blood cell (WBC) count is important in assessing the immune system's ability to fight infection, a WBC of 5,000/mm³ is within the normal range (4,500 to 11,000 WBCs/mm³). Therefore, it is not the most critical value for a nurse to prioritize in the care of an HIV patient.
Choice B reason:
A platelet count of 150,000/mm³ is also within the normal range (150,000 to 450,000 platelets/mm³). Although thrombocytopenia can occur in HIV, this value does not indicate an immediate concern for the nurse to prioritize.
Choice C reason:
A positive Western blot test confirms the presence of HIV antibodies, which is indicative of HIV infection. However, this is a diagnostic result rather than a laboratory value that reflects the current status of the patient's immune function or disease progression.
Choice D reason:
The CD4-T-cell count is a critical laboratory value for assessing the immune function of a patient with HIV. A count of 180 cells/mm³ is below the normal range of 500 to 1,200 cells/mm³ and indicates a significantly weakened immune system, placing the patient at risk for opportunistic infections. This value is a priority as it guides treatment decisions and the need for prophylaxis against opportunistic infections.
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.
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