A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

The client reports numbness at the site.

Purulent drainage noted from the site

Skin over the site is sloughing

The vein appears cord-like

Answer and Explanation

The Correct Answer is B

A) The client reports numbness at the site: Numbness at the insertion site is not a typical finding of infection. It may indicate nerve damage or another issue but is not specific to infection.

B) Purulent drainage noted from the site: Purulent drainage, characterized by pus-like discharge, is a common sign of infection at the insertion site of an intravenous catheter. It suggests the presence of bacteria and inflammation at the site.

C) Skin over the site is sloughing: Sloughing of the skin may occur with severe tissue damage but is not specific to infection. It could indicate other complications such as tissue necrosis or chemical irritation.

D) The vein appears cord-like: A cord-like appearance of the vein, known as thrombophlebitis, can occur with or without infection. It indicates inflammation and clot formation within the vein, which can be a complication of intravenous catheter insertion, but it does not specifically indicate infection.

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Correct Answer is ["A","B","C"]

Explanation

A) A client who has had a cerebrovascular accident:
Clients who have had a cerebrovascular accident (stroke) often suffer from dysphagia (difficulty swallowing) due to impaired muscle control or sensory deficits. This makes them more susceptible to aspiration, as food or liquid can enter the airway instead of the esophagus.

B) A client who has had radiation therapy for head and neck cancer:
Radiation therapy in the head and neck area can cause damage to tissues, leading to mucositis, fibrosis, and reduced salivary flow, all of which can impair swallowing function. This increases the risk of aspiration because the normal mechanisms that protect the airway during swallowing may be compromised.

C) A client who is 4 hr postoperative following a leg amputation with general anesthesia:
General anesthesia can depress the gag and cough reflexes and impair coordination of the muscles involved in swallowing, making it more difficult for the client to protect their airway. This increased risk of aspiration is particularly relevant in the immediate postoperative period when the effects of anesthesia may still be present.

D) A client who has lactose intolerance:
Lactose intolerance primarily affects the digestive system and does not directly impact the mechanics of swallowing or increase the risk of aspiration. This condition leads to gastrointestinal symptoms such as bloating, diarrhea, and abdominal pain when consuming lactose-containing foods, but it does not increase the risk of food or liquid entering the airway during eating.

E) A client who has had prolonged diarrhea:
Prolonged diarrhea can lead to dehydration and electrolyte imbalances, but it does not directly affect the swallowing mechanism or increase the risk of aspiration. The primary concern with prolonged diarrhea is fluid and electrolyte management rather than an increased risk of aspiration during eating.

A. "The health care proxy does not go into effect until I am incapable of making decisions." B. "I have to choose a family member as my health proxy." C. "If I become incapacitated, end-of-life choices will be made by my proxy." D. "I can change who I designate as my health care proxy at any time."

Correct Answer is B

Explanation

A) "The health care proxy does not go into effect until I am incapable of making decisions.": This statement is accurate. A health care proxy, also known as a durable power of attorney for health care or health care agent, is appointed to make medical decisions on behalf of the client if they become unable to do so themselves. This can include decisions related to treatment options, end-of-life care, and other medical interventions.

B) "I have to choose a family member as my health proxy.": This statement is incorrect. While some individuals may choose a family member as their health care proxy, it is not a requirement. The client can choose any competent adult who is willing to serve as their health care proxy, including a friend, relative, or even a legal representative.

C) "If I become incapacitated, end-of-life choices will be made by my proxy.": This statement is accurate. The health care proxy is responsible for making medical decisions on behalf of the client if they are unable to do so, including decisions related to end-of-life care and treatment preferences.

D) "I can change who I designate as my health care proxy at any time.": This statement is accurate. The client has the right to change their health care proxy at any time by completing a new advance directive document and revoking any previous designations. It is essential for the client to review and update their advance directives regularly to ensure they reflect their current wishes and preferences.

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A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is B

Explanation

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