A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the client's IV site was reddish in color and showing signs of inflammation
The nurse recognizes that what phenomenon is likely responsible? A) Phlebitis
B) Thrombus formation
C) Pulmonary embolus
D) Air embolism
A
Feedback:
The nurse should record that the client has phlebitis, which is an inflammation of the vein. Thrombus formation is a situation in which there is stationary blood clot. Pulmonary embolus is a situation in which the blood clot travels to the lung. Air embolism is a bubble of air traveling within the vascular system.
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Which statement is true regarding the recording of data from the history and physical examination?
a. Use long, descriptive sentences to document findings. b. Record the data as soon as possible after the interview and physical examination. c. If the information is not documented, then it can be assumed that it was done as a standard of care. d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.
The theory of aging that suggests there should be a natural withdrawal between the individual and society is the:
a. free radical theory. b. autoimmunity theory. c. wear-and-tear theory. d. disengagement theory.
The nurse working in the delivery room assesses a newborn infant delivered vaginally. The infant has a strong cry, is moving all extremities vigorously, and its color is pink. Which action by the nurse is the priority?
1. Stimulate the infant. 2. Encourage infant-maternal bonding. 3. Dry the infant. 4. Administer oxygen.
With which class of drugs would the nurse be most likely to see Stevens-Johnson syndrome?
a. Sulfonamides b. Tetracyclines c. Azoles d. Penicillins