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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Correct Answer is A

Explanation

Choice A rationale

Lying on the left side can help minimize the effects of reflux during sleep. This position helps keep the stomach contents lower than the esophagus, reducing the likelihood of acid reflux.

Choice B rationale

Lying on the right side can increase the risk of acid reflux. This position allows the stomach contents to flow more easily into the esophagus, exacerbating reflux symptoms.

Choice C rationale

Sleeping on the back with the head flat can worsen reflux symptoms. This position allows stomach acid to flow back into the esophagus more easily, increasing the risk of reflux.

Choice D rationale

Sleeping on the stomach with the head flat is not recommended for clients with GERD. This position can increase pressure on the stomach, promoting acid reflux into the esophagus.

A. A client whose daily caloric intake is 25% fat. B. A client who has diabetes mellitus. C. A client who consumes two 12-ounce (0.35-L) alcoholic beverages daily. D. A client who has hypothyroidism.

Correct Answer is B

Explanation

Choice A rationale

A daily caloric intake of 25% fat is within the recommended range and does not significantly increase the risk for peripheral arterial disease (PAD).

Choice B rationale

Diabetes mellitus is a significant risk factor for PAD. High blood sugar levels can damage blood vessels and lead to poor circulation.

Choice C rationale

Consuming two 12-ounce alcoholic beverages daily can contribute to other health issues but is not a primary risk factor for PAD.

Choice D rationale

Hypothyroidism is not directly linked to an increased risk of PAD. It can cause other cardiovascular issues but not specifically PAD.

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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

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Correct Answer is A

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