The nurse reviews the nursing notes and vital signs for a client. On 2/5 at 0900, cultures were obtained and delivered to the lab for analysis.The client was discharged home with wound care instructions and prescribed broad-spectrum oral antibiotic therapy.
On 2/7, the nurse assesses the client for bowel movements, temperature, pain, and wound status. Based on the subjective report, which finding would indicate a complication?

Choice A rationale

The nurse correctly identifies that 50 bowel sounds per minute exceed the normal range of 5 to 30 sounds per minute, warranting the classification of hyperactive. This increased frequency of peristaltic waves is a classic sign of hypermotility in the gastrointestinal tract. When the intestines move this rapidly, there is insufficient time for the colon to reabsorb water from the fecal matter, which typically results in the client experiencing frequent, loose, or watery stools known as diarrhea.

Choice B rationale

Hypoactive bowel sounds represent a decrease in the frequency of intestinal contractions, usually defined as fewer than 5 sounds per minute. This slow motility allows for excessive water reabsorption, leading to hard stools and constipation. Because the client has 50 sounds per minute, this choice is scientifically inaccurate. The findings do not support a diagnosis of constipation, which is physiologically characterized by a lethargic or slowed gastrointestinal transit time and reduced frequency of bowel sounds.

Choice C rationale

Borborygmi are loud, rumbling sounds caused by the movement of gas through the intestines, and while they can be associated with hyperactive states, they are specifically the sound rather than the rate. While high-pitched, tinkling sounds can occur proximal to an intestinal obstruction, the most common clinical association for a general rate of 50 sounds per minute is diarrhea. Obstruction eventually leads to silent or absent sounds distal to the blockage, making diarrhea the more immediate anticipation.

Choice D rationale

Documenting 50 sounds per minute as normal is a clinical error because the standard physiological range for bowel sounds is 5 to 30 per minute. Expecting regular movements based on this data ignores the evidence of gastrointestinal distress. Normal bowel sounds suggest a balanced rate of peristalsis and fluid absorption. The presence of 50 sounds per minute is a clear deviation from homeostasis, indicating that the client's digestive process is currently accelerated and likely to be problematic.

Choice A rationale

Swelling and coolness at the insertion site are classic indicators of infiltration, which occurs when intravenous fluid enters the surrounding subcutaneous tissue instead of the vein. Infiltration can lead to tissue damage or necrosis depending on the infusate. Normal skin temperature should be maintained at the site. Because the fluid is no longer entering the vascular system, the nurse must immediately stop the infusion and restart the access at a different proximal location to ensure safety.

Choice B rationale

The presence of yellow drainage, or purulence, at the insertion site is a significant sign of localized infection or exit site involvement. This indicates that pathogens have potentially bypassed the skin barrier, posing a risk for systemic bacteremia or sepsis. Standard nursing practice requires the immediate removal of the catheter to prevent further microbial proliferation. The site should be treated, and any subsequent intravenous access must be established at a new, uncontaminated site to protect the client.

Choice C rationale

Tenderness and redness along the path of the vein are hallmark signs of phlebitis, which is inflammation of the inner layer of the vein. This can be caused by chemical irritation, mechanical trauma from the catheter, or bacterial presence. Phlebitis is graded on a scale, but any visible redness and pain necessitate stopping the therapy at that site. Failure to do so can lead to thrombus formation or permanent venous scarring, compromising future vascular access options.

Choice D rationale

When an intravenous fluid stop flowing due to arm position, it is often a mechanical issue related to the catheter tip pressing against a vein wall or a valve. This is considered a positional IV rather than a site failure requiring removal. Adjusting the arm or using an arm board typically resolves the flow rate without needing a new puncture. This finding does not inherently indicate infiltration, infection, or phlebitis, so the access site remains viable for use.

Choice E rationale

Pain without any visible or palpable abnormalities like swelling, redness, or warmth may indicate minor nerve irritation or simple discomfort from the tape or dressing. While the nurse should monitor the site closely, isolated pain does not meet the diagnostic criteria for mandatory site rotation or therapy cessation. The nurse should first assess for external causes of discomfort. If no signs of complication develop, the current access can be maintained while continuing to monitor the client.