A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
Coolness
Drainage
Pallor
Erythema
The Correct Answer is D
A. Coolness at the IV insertion site is not a typical sign of phlebitis. Phlebitis often presents with warmth or increased heat around the vein due to inflammation.
B. Drainage at the IV site might indicate infection or other complications but is not a specific sign of phlebitis. Phlebitis primarily manifests as redness, tenderness, and swelling along the vein.
C. Pallor (pale coloration) at the IV site is not a typical sign of phlebitis. Phlebitis usually presents with redness or erythema due to inflammation.
D. Erythema (redness) at the IV catheter insertion site is a hallmark sign of phlebitis. It indicates inflammation of the vein where the catheter is placed and is a common early sign of phlebitis. Other signs include warmth, tenderness, and swelling along the vein.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Unlike an x-ray, the MRI allows you to move around a bit":
This statement is not accurate. During an MRI, it is important for the client to remain as still as possible to obtain clear images. Movement can result in blurred images.
B. "Your exposure to radiation will be minimal":
This statement is not applicable to MRI, as MRI does not use ionizing radiation. It uses a strong magnetic field and radio waves to generate images, making it different from x-rays in terms of radiation exposure.
C. "You will not be able to talk to the technician during the procedure":
While it is essential for the client to remain still during an MRI, communication with the technician is generally possible through an intercom system. The client may be given instructions and reassurance during the procedure.
D. "You'll have to remove metal objects such as watches and body jewelry":
This is the correct statement. Metal objects can interfere with the magnetic field used in MRI and can pose a safety risk. Therefore, clients are required to remove any metal objects before undergoing an MRI.
Correct Answer is A
Explanation
A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.
B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.
C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.
D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.
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