While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
a. "Grade 3 phlebitis at IV site"
b. "Infection at IV site"
c. "Thrombosed area at IV site"
d. "Infiltration at IV site"
ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the description indicates that infection, thrombosis, or infiltration is present.
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