A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Coolness of the client's left forearm

Pallor of the client's left forearm

Erythema along the path of the vein

Pitting edema at the insertion site

Answer and Explanation

The Correct Answer is C

The rationale for this answer is that phlebitis is inflammation of a vein caused by mechanical, chemical, or bacterial irritation from an IV catheter or fluid. It manifests as redness, warmth, tenderness, and swelling along the path of the vein.

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Correct Answer is A

Explanation

Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.

A. Wearing gloves when performing perineal care B. Failing to don a mask when entering a client's isolation room C. Cleansing visibly fecal-soiled hands with alcohol-based hand rub D. Putting on a protective gown before entering a client's room

Correct Answer is C

Explanation

Cleansing visibly fecal-soiled hands with alcohol-based hand rub is a possible source of infection because alcohol-based hand rubs are not effective against Clostridium difficile spores. The nurse should wash his or her hands with soap and water for at least 15 seconds after contact with fecal material or surfaces contaminated with feces.

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A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Correct Answer is A

Explanation

A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Correct Answer is C

Explanation

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A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

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