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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering diphenhydramine with food does not specifically address the adverse effect of dry mouth. While taking the medication with food can help reduce gastrointestinal side effects, it does not alleviate dry mouth.
Choice B rationale
Chewing on sugarless gum or sucking on hard candies can help stimulate saliva production and alleviate dry mouth. This is an effective and simple measure to manage the adverse effect of dry mouth associated with diphenhydramine.
Choice C rationale
Placing a humidifier at the bedside can help maintain moisture in the air, but it is not the most effective measure for managing dry mouth. Chewing gum or sucking on candies directly stimulates saliva production, providing more immediate relief.
Choice D rationale
Discontinuing the medication and notifying the provider is not necessary for managing dry mouth. Dry mouth is a common and manageable side effect of diphenhydramine. Simple measures like chewing gum or sucking on candies are usually sufficient to alleviate this symptom
Correct Answer is C
Explanation
Choice A rationale
Friction rub is not a typical complication of endocarditis. It is more commonly associated with pericarditis, which is inflammation of the pericardium.
Choice B rationale
Intermittent claudication is not a complication of endocarditis. It is typically associated with peripheral artery disease, which affects blood flow to the limbs.
Choice C rationale
Cardiac murmur is a common finding in endocarditis. The infection can cause damage to the heart valves, leading to abnormal heart sounds or murmurs.
Choice D rationale
Dependent rubor is not a complication of endocarditis. It is usually associated with peripheral artery disease and is characterized by redness of the lower extremities when they are in a dependent position.
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