A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

The area surrounding the insertion site feels warm to the touch.

The infusion rate has stopped but the tubing is not kinked.

There is fluid leaking around the insertion site.

There is no blood return when the tubing is aspirated.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Warmth around the IV insertion site is a classic sign of phlebitis, which is inflammation of the vein. This can be caused by irritation from the IV catheter or the infusing solution.

Choice B rationale

A stopped infusion rate without a kinked tubing could indicate an occlusion or infiltration, but it is not a specific sign of phlebitis.

Choice C rationale

Fluid leaking around the insertion site suggests infiltration or extravasation, where the IV fluid leaks into the surrounding tissue, rather than phlebitis.

Choice D rationale

Lack of blood return when aspirating the tubing could indicate a positional issue or occlusion, but it is not specific to phlebitis.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Based on the provided information, the client is most likely experiencing Anemia. Here’s how the diagram should be completed:
Condition

Anemia

Actions to Take

Administer prescribed medications
Monitor vital signs regularly

Parameters to Monitor

Hemoglobin levels
Blood pressure

A. “Soon those shock waves will get rid of my gallstones.”. B. “I’ll have a camera put down my throat so they can see my gallbladder.”. C. “They are going to use dye to examine my gallbladder and ducts.”. D. “They’ll put medication into my gallbladder to dissolve the stones.”.

Correct Answer is C

Explanation

Choice A rationale

Lithotripsy, which uses shock waves to break up stones, is not part of an oral cholangiogram. An oral cholangiogram involves the use of a contrast dye to visualize the gallbladder and bile ducts on X-ray.

Choice B rationale

An endoscopic procedure, such as an endoscopic retrograde cholangiopancreatography (ERCP), involves inserting a camera down the throat. However, an oral cholangiogram is a non- invasive imaging test that uses contrast dye.

Choice C rationale

Correct. An oral cholangiogram involves the ingestion of a contrast dye that helps visualize the gallbladder and bile ducts on X-ray.

Choice D rationale

Medications to dissolve gallstones are not used in an oral cholangiogram. This procedure is purely diagnostic and involves the use of contrast dye to visualize the gallbladder and bile ducts.

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A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?

Correct Answer is C

Explanation

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