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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F","G"]
Explanation
Choice A rationale
Potassium level is not directly related to wound healing. While potassium is essential for overall cellular function, it does not have a direct impact on the wound healing process.
Choice B rationale
Pre-albumin level is a marker of nutritional status. Low pre-albumin levels indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for the synthesis of collagen and other proteins involved in the wound healing process.
Choice C rationale
History of diabetes mellitus can significantly delay wound healing. High blood glucose levels can impair immune function, reduce blood flow, and increase the risk of infection, all of which can delay the healing process.
Choice D rationale
History of hyperlipidemia is not directly related to wound healing. While hyperlipidemia can contribute to other health issues, it does not have a direct impact on the wound healing process.
Choice E rationale
Wound infection is a major factor that can delay wound healing. Infection can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.
Choice F rationale
Decreased pedal perfusion indicates poor blood flow to the extremities. Adequate blood flow is essential for delivering oxygen and nutrients to the wound site, and poor perfusion can delay the healing process.
Choice G rationale
Fasting blood glucose levels are an indicator of blood sugar control. High fasting blood glucose levels can impair immune function and increase the risk of infection, both of which can delay wound healing.
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
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