A nurse is monitoring a client following the insertion of a peripheral intravenous catheter. Which of the following findings should indicate to the nurse that the client is experiencing phlebitis at the insertion site?
Leakage of IV fluid
Blood leakage
Red streak
Purulent drainage
The Correct Answer is C
Rationale:
A. Leakage of IV fluid: Leakage of IV fluid at the insertion site suggests infiltration, not phlebitis. In infiltration, fluid escapes into surrounding tissues, leading to swelling and coolness, but not inflammation of the vein itself.
B. Blood leakage: Blood leakage is usually related to poor catheter stabilization or improper insertion, not phlebitis. It does not indicate inflammation or irritation of the vein wall, which are hallmark signs of phlebitis.
C. Red streak: A red streak following the path of the vein is a classic sign of phlebitis. It indicates inflammation of the vein wall and is often accompanied by pain, warmth, and swelling along the vein.
D. Purulent drainage: Purulent drainage is a sign of infection rather than phlebitis. While phlebitis can lead to infection if untreated, purulent drainage points to a more serious complication involving bacterial growth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Rationale:
• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.
• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.
• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.
• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.
Correct Answer is A
Explanation
Rationale:
A. Preeclampsia: Methylergonovine causes vasoconstriction and increases blood pressure, which can be dangerous in clients with preeclampsia. Administering this medication in such cases can elevate the risk of stroke or seizure due to worsening hypertension.
B. An allergy to penicillin: Methylergonovine is not a penicillin-based medication, so a penicillin allergy does not present a known contraindication or concern. Caution is unnecessary unless there is a known allergy to ergot alkaloids.
C. Gestational diabetes mellitus: Methylergonovine does not significantly impact blood glucose levels or insulin sensitivity. Therefore, it can be used safely in clients with gestational diabetes when indicated for hemorrhage control.
D. Cholelithiasis: There is no direct interaction or exacerbation of gallbladder disease with methylergonovine. The medication primarily acts on uterine smooth muscle and vascular tone, not on the biliary system.
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