A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Streak formation along the vein

Erythema at the insertion site

Blistering around the insertion site

Warmth at insertion site

Damp dressing over the insertion site

Answer and Explanation

Correct Answer : A,B,D

A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.

B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.

C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.

D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.

E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.

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Correct Answer is A

Explanation

A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.

B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.

C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.

D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.

A. 25% albumin B. Dextrose 10% in water C. Dextrose 5% in water D. Dextran 40

Correct Answer is C

Explanation

C. Dextrose 5% in water is a hypotonic solution that contains 5 grams of dextrose in each 100 mL of water. It provides free water without adding significant sodium, which helps to dilute the elevated sodium levels in hypernatremia. This solution is effective in correcting hypernatremia by promoting water movement from the intravascular space into the cells and extracellular space.

A. Albumin solutions are primarily used for volume expansion and to increase oncotic pressure in conditions like hypoalbuminemia or shock. They do not provide free water and are not typically used for treating hypernatremia.

B. Dextrose 10% in water is a hypertonic solution used primarily for providing calories and treating hypoglycemia. It does not correct hypernatremia because it does not significantly affect sodium levels or provide sufficient free water to dilute sodium.

D. Dextran 40 is a colloid solution that is used for volume expansion in hypovolemia or shock. It does not provide free water and is not indicated for correcting hypernatremia.

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A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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