A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Encourage the client to make choices regarding hygiene.

Oﬀer the client sips of a citrus ﬂavored soda.

Position the client supine in bed.

Suction the client's airway every hour.

Answer and Explanation

The Correct Answer is A

When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.

Option b is incorrect because oﬀering the client sips of a citrus ﬂavored soda may not be appropriate for all clients and should be based on individual preferences and needs.

Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.

Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.

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Correct Answer is A

Explanation

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

A. Use a cuﬀ with a width that is about 60% of the client's arm circumference. B. Apply the cuﬀ above the client's antecubital fossa. C. Have the client sit with his arm resting above the level of his heart. D. Release the pressure on the client's arm 5 to 6 mm per second.

Correct Answer is A

Explanation

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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