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
Explanation
Choice A rationale
A diet high in carbohydrates is not specifically recommended for diverticulitis during the asymptomatic period. While carbohydrates are an essential part of a balanced diet, they do not specifically aid in preventing diverticulitis flare-ups. Instead, a high-fiber diet is more beneficial as it helps in maintaining regular bowel movements and preventing constipation, which can reduce the risk of diverticula formation and inflammation.
Choice B rationale
A diet high in fiber is recommended during the asymptomatic period of diverticulitis. Fiber helps to soften the stool and increase its bulk, which can prevent constipation and reduce pressure on the colon. This can help prevent the formation of diverticula and reduce the risk of diverticulitis flare-ups. Foods high in fiber include fruits, vegetables, whole grains, and legumes.
Choice C rationale
A low-residue diet is typically recommended during an acute diverticulitis flare-up to reduce bowel movements and allow the colon to heal. However, during the asymptomatic period, a high-fiber diet is more beneficial in preventing future flare-ups.
Choice D rationale
A diet low in fat is not specifically recommended for diverticulitis. While reducing fat intake can be beneficial for overall health, it does not specifically address the prevention of diverticulitis flare-ups. A high-fiber diet is more effective in maintaining bowel health and preventing diverticulitis.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.
Choice B rationale
Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.
Choice C rationale
Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.
Choice D rationale
Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.
Choice E rationale
Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.
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