When assessing the client's peripheral IV site, the nurse observes a streak of red along the vein path and can palpate a 4-cm venous cord. What is the most accurate documentation of this finding?
A. IV infiltration/extravasation with a 4-cm area of erythema and edema
B. Thrombosis and infection of IV site
C. Grade 3 phlebitis at IV site
D. Grade 1 phlebitis at IV site
C
The presence of a red streak and palpable cord indicate grade 3 phlebitis. There is no information in the description to indicate that infection, infiltration, extravasation, or thrombosis is present.
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X : 300 = 2 : 60
x = _____ a. 1,800 b. 10 c. 2.5 d. 9,000
A hospital patient has a large, superficial wound on her elbow that was the result of shearing action when she was moved up in her bed
The patient's husband mentions that the wound looks infected and irritated because the wound bed is completely red. Which of the following responses would be inappropriate? A) "Even though it is red, it doesn't mean that the wound is infected." B) "The red areas show that there is enough circulation to facilitate healing." C) "Those are fresh blood vessels that are a sign of healthy healing." D) "A thin sheet of blood clotting is actually desirable and not a sign that your wife's wound is infected."
What is the priority nursing intervention for the client during the first 24 hours after a skin graft procedure?
A. Monitoring of vital signs for early detection of hemorrhage B. Monitoring of graft site to assess "take" of the newly grafted skin C. Repositioning the client every 2 hours to prevent pressure ulcer formation D. Performing passive range-of-motion exercises on the extremity with the new graft to prevent contracture development
A nurse is participating as a speaker in a public workshop on the topic of promoting mental health in young and middle-aged adults
The nurse tells the audience that age, unemployment, and lower education are risk factors associated with mental illness. A woman raises her hand and asks, "Does that mean because I only have a 10th grade education and am unemployed that I will develop a mental illness?" Which response by the nurse would be most appropriate? A) "No, not necessarily; it just means that there is an increased chance that you might." B) "Of course not; we live in a rural area, and these statistics are based on large cities." C) "Yes, I am afraid so, but with early detection, we can prevent the illness from worsening." D) "It probably does, but we have developed advanced medications to treat mental illness."