A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.
Which of the following actions should the nurse plan to take?

Apply a pressure dressing at the IV site.

Place a warm, moist compress on the site.

Express drainage from the IV site and send it to be cultured.

Insert a new IV catheter distal to the discontinued IV site.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.

Choice B rationale:

Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.

Choice C rationale:

Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.

Choice D rationale:

Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Answer is: b. Document the client's condition every 15 min.

Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.

Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.

Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.

Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.

A. Ensuring that creases in the stockings are on the front of the client's legs B. Applying the stockings before the client gets out of bed C. Asking the client to point their toes before applying the stockings D. Turning the stockings inside out before applying them

Correct Answer is A

Explanation

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is appropriate, as it ensures proper application and minimizes the risk of injury due to the client's leg swelling

Choice C rationale:

Asking the client to point their toes before applying the stockings is appropriate, as it helps with correct placement and reduces the risk of skin damage or discomfort

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

View Question and Answer

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

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is B

Explanation

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take?

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

A nurse is admitting a client to a medical-surgical unit.When performing medication reconciliation for the client, which of the following actions should the nurse take?

A nurse in a long-term care facility is admitting a client who has dementia.Which of the following actions should the nurse take to reduce the risk for client injury?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium?

A nurse is reviewing the medical history of a client who asks about the use of warfarin.The nurse should identify which of the following findings as a contraindication for the administration of this medication?

A nurse is speaking with the caregiver of a client who has Alzheimer's disease.The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take?

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.
Which of the following actions should the nurse plan to take?