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

Explanation

A. Lavender:
Lavender essential oil is well-known for its calming and relaxing properties. It is often used to promote sleep and alleviate insomnia symptoms. Research suggests that inhaling lavender aroma or using lavender oil in aromatherapy can help improve sleep quality by reducing anxiety and promoting relaxation.

B. Orange:
While orange essential oil has a refreshing and uplifting scent, it is not typically used to promote sleep. Instead, it is often used to boost mood and energy levels due to its citrusy aroma.

C. Peppermint:
Peppermint essential oil has a stimulating and invigorating scent, making it more suitable for promoting alertness and mental clarity rather than inducing sleep. It is commonly used to alleviate fatigue and increase focus.

D. Ginger:
Ginger essential oil has a warm and spicy aroma that is often used for its energizing and revitalizing effects. Similar to peppermint, ginger is not typically used to promote sleep but may help alleviate fatigue and increase mental alertness.

A. Administer 200 mL of formula during the initial infusion B. Give the initial feeding over 15 min. C. Reconstitute the formula with tap water D. Discard unused formula after 8 hr.

Correct Answer is D

Explanation

A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.

B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.

C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.

D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.

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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?

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Naxlex Comprehensive Predictor Exams

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