A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching?

Answer: (B, C, D, E)

Rationale:

A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.

B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.

C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.

D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.

E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.

A. Insert the needle slowly and gently.

This statement is generally true for most injection techniques, including the Z-track method. Slow and gentle insertion helps minimize discomfort for the client and allows for better control over the needle's placement. However, the specific speed of insertion may vary depending on the nurse's technique and the client's skin condition.

B. Pull the skin 1.3 cm (1/2 inch) to the side.

This statement is correct. The Z-track technique involves pulling the skin laterally (to the side) by approximately 1.3 cm (1/2 inch) before inserting the needle. This lateral displacement of the skin creates a zigzag pathway for the medication, which helps prevent leakage or tracking of the medication along the injection site.

C. Aspirate for 5 to 10 seconds.

Aspiration, or pulling back on the plunger of the syringe after needle insertion, is not typically recommended for intramuscular injections, including those using the Z-track method. Aspiration may increase the risk of tissue trauma or damage to blood vessels. Since the Z-track technique is designed to minimize medication leakage into the subcutaneous tissue, aspiration is usually unnecessary.

D. Use a 45° angle of insertion.

The angle of insertion for the Z-track technique is typically 90 degrees (perpendicular) to the skin surface rather than 45 degrees. This angle allows for proper depth penetration into the muscle and ensures adequate delivery of the medication into the muscle tissue.