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:
Notifying the client that they will receive a food tray in the recovery room is not typically a priority in preoperative education. Nutritional status post-surgery is important, but immediate postoperative care focuses on recovery from anesthesia and monitoring for complications.

Choice B reason:
Reminding the client that they will return to their room after surgery is part of routine information that may help orient the patient postoperatively. However, it is not a specific intervention that will aid in the recovery process or prevent complications.

Choice C reason:
Informing the client that the recovery nurse will instruct them on how to manage postoperative pain is important, but it is not the primary focus of preoperative education. Pain management is typically addressed both preoperatively and postoperatively.

Choice D reason:
Providing instructions on how to cough and deep breathe effectively is a critical component of preoperative education for clients undergoing abdominal surgery. Effective coughing and deep breathing exercises help prevent postoperative complications such as pneumonia and atelectasis by promoting lung expansion and secretion clearance.

A. Concurrent treatment for GERD B. History of breast cancer C. Multiple hospitalizations for COPD D. History of dermatitis

Correct Answer is B

Explanation

While GERD (gastroesophageal reflux disease) can be exacerbated by hormone therapy due to its potential effect on the lower esophageal sphincter, it is not typically a contraindication for HT unless the GERD is severe and not well controlled with treatment.

Choice B reason:
A history of breast cancer is a contraindication for hormone therapy. Estrogen can stimulate the growth of hormone receptor-positive breast cancers, and therefore, HT is not recommended for individuals with a current or past history of breast cancer.

Choice C reason:
COPD (chronic obstructive pulmonary disease) is not a contraindication for HT. While patients with COPD may have other comorbidities that could affect the safety of HT, COPD alone does not preclude the use of hormone therapy.

Choice D reason:
Dermatitis, or inflammation of the skin, is not a contraindication for HT. Skin conditions are not typically affected by hormone therapy, and HT may sometimes be beneficial for skin health during menopause.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for abdominal surgery. Which of the following nursing interventions should the nurse include in the preoperative education?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?

Correct Answer is B

Explanation

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?

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A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A nurse is reviewing the medical record of a male client who has chlamydia. Which of the following factors contribute to the client's risk of chlamydia? (Select all that apply.)

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A nurse is teaching a client who has a pelvic fracture about the manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?