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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Disenfranchised grief:
Disenfranchised grief occurs when the loss experienced by an individual is not openly acknowledged or socially supported. This type of grief may occur when the relationship with the deceased is not recognized or valued by others, such as in the case of a non-traditional relationship. In this scenario, the client's grief is acknowledged but persists beyond what is considered a typical mourning period, suggesting a different type of grief.
B. Anticipatory grief:
Anticipatory grief occurs when individuals experience feelings of loss before the actual loss or death occurs. This often happens in situations where death is expected due to a terminal illness. Since the client's partner has already died, anticipatory grief does not apply in this case.
C. Prolonged grief:
This is the correct answer. Prolonged grief, also known as complicated grief, occurs when the grieving process persists over an extended period, beyond what is considered typical or socially acceptable. Individuals experiencing prolonged grief may have difficulty accepting the reality of the loss and may continue to experience intense emotions related to the loss for an extended period, often interfering with their daily functioning.
D. Uncomplicated grief:
Uncomplicated grief refers to a normal and typical response to loss that typically resolves over time. While grief is a natural response to loss, uncomplicated grief does not persist for an extended period or significantly impair the individual's ability to function in their daily life. In this scenario, the client's continued inability to accept the loss suggests that the grief may be more complex than uncomplicated grief.
Correct Answer is A
Explanation
A) An older adult who is confused and has urinary frequency:
This client is at the greatest risk for a fall due to several factors. Confusion increases the likelihood of disorientation and impaired judgment, leading to accidents. Urinary frequency may necessitate frequent trips to the bathroom, increasing the chances of falls, especially if the client is disoriented or unsteady on their feet.
B) An older adult with hearing impairment:
While hearing impairment can contribute to a fall risk by limiting the client's ability to hear warnings or instructions, it may not pose as immediate a risk as confusion and urinary frequency, which directly affect mobility and judgment.
C) A client who has a dressing on his foot due to a pressure ulcer:
While having a dressing on the foot due to a pressure ulcer increases the risk of falls by potentially affecting the client's gait and balance, it may not be as significant a risk factor as confusion and urinary frequency, which directly impact the client's ability to safely navigate their environment.
D) A client who has osteoarthritis and uses a walker:
Although osteoarthritis and the use of a walker can contribute to mobility issues and an increased risk of falls, they may not present as immediate a risk as confusion and urinary frequency, which can lead to more unpredictable and hazardous situations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.