The nurse notes redness and tenderness at the patient's IV insertion site. What should the nurse do next?
Apply a warm compress to the IV site
Flush the IV line with normal saline to check patency
Remove the IV and restart it in another location
Document the finding and continue to monitor
The Correct Answer is C
Phlebitis is inflammation of a vein characterized by erythema, tenderness, warmth, and possible cordlike induration at the insertion site. It results from mechanical irritation, chemical infusion, or infection. Immediate catheter removal prevents thrombosis and systemic complications.
Rationale:
A. Applying a warm compress may reduce discomfort after catheter removal but does not address the underlying cause. Continuing infusion through an inflamed vein worsens vascular injury and increases infection risk. The presence of redness and tenderness necessitates discontinuation first.
B. Flushing the IV line assesses patency but is contraindicated when phlebitis is suspected. Forcing fluid through an inflamed vein can exacerbate endothelial damage and increase risk of infiltration or thrombosis. Pain and erythema indicate the line should not be used.
C. Removal of the IV catheter is the priority intervention when signs of phlebitis are present. This prevents progression to thrombophlebitis and systemic infection. Establishing a new site maintains therapy while eliminating the source of inflammation and vascular compromise.
D. Documentation and monitoring alone are insufficient because phlebitis can progress rapidly if the catheter remains in place. Delayed intervention increases risk of complications such as thrombosis or infection. Active signs like tenderness and redness require immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Tonsillar grading is a clinical assessment system used to quantify tonsillar hypertrophy based on oropharyngeal space obstruction. Enlargement occurs due to lymphoid tissue hyperplasia from recurrent infection or chronic inflammation, affecting airway patency, swallowing, and speech resonance depending on degree of obstruction.
Rationale:
A. Halfway to uvula corresponds to a lower grade of tonsillar enlargement, typically 2+, where tonsils extend between tonsillar pillars and uvula but do not reach midline. This does not represent severe hypertrophy and is less than the documented 3+ classification.
B. Barely visible tonsils represent minimal enlargement, typically 1+, where tissue is confined within tonsillar pillars. This indicates near-normal size with minimal or no airway obstruction and does not correlate with a 3+ grading system.
C. Touching each other describes “kissing tonsils,” which is 4+ grading, indicating complete midline contact and significant airway obstruction. This is more severe than 3+ and represents near-complete oropharyngeal space occlusion rather than moderate enlargement.
D. Touching uvula corresponds to 3+ tonsillar hypertrophy, where tonsils are enlarged and extend toward the midline, contacting or nearing the uvula without full bilateral contact. This reflects significant but not complete airway obstruction and matches the documented assessment finding.
Correct Answer is D
Explanation
Tracheal deviation indicates a significant intrathoracic pressure imbalance resulting in mediastinal displacement due to severe pulmonary pathology, most commonly associated with tension pneumothorax, mediastinal shift, lung collapse, and hypoxia requiring emergency intervention oxygen resuscitation
Rationale:
A. Unilateral lymphadenopathy does not produce tracheal deviation because lymph node enlargement is confined to cervical chains. It does not alter intrathoracic pressure dynamics. Therefore it is not associated with mediastinal shift or acute airway compromise requiring emergency intervention clinically irrelevant
B. Goiter may cause anterior neck mass and rarely tracheal deviation when significantly enlarged. However deviation is typically gradual rather than acute. It is not associated with sudden mediastinal shift or life-threatening ventilation compromise requiring emergency decompression clinically progressive condition usually
C. Cervical muscle spasm may produce neck discomfort and limited range of motion but does not affect intrathoracic structures. It cannot cause tracheal deviation or mediastinal shift and is not associated with respiratory compromise or emergent airway pathology clinically benign condition
D. Tension pneumothorax on the right side causes increased intrapleural pressure leading to mediastinal shift away from affected lung. This results in tracheal deviation, reduced venous return, hypoxia, and rapid cardiopulmonary collapse requiring immediate decompression life threatening emergency condition requires intervention
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