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Author Question: The nurse caring for a client with phlebitis at the old IV site assesses the site and finds that the ... (Read 30 times)

vicky

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The nurse caring for a client with phlebitis at the old IV site assesses the site and finds that the site is painful and edematous, with no palpable cord extending one inch above the site.
 
  The nurse categorizes the site as which of the following on the phlebitis scale? 1. 1+
  2. 2+
  3. 3+
  4. 4+

Question 2

The client reports that the IV site hurts. The nurse assesses the site, and it appears normal, without redness, edema, drainage, or any indication of complications. What is the nurse's priority intervention?
 
  1. Discontinue the infusion.
  2. Notify the physician.
  3. Slow the rate of infusion.
  4. Notify the RN.



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wfdfwc23

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Answer to Question 1

2
Rationale: Edema places this site above a 1+, and the lack of palpable cord indicates it is not a 3+, so the site is categorized as a 2+ on the phlebitis scale.

Answer to Question 2

4
Rationale: The nurse should notify the RN, who will assess the client further. The infusion should not be discontinued because the discomfort could be caused by caustic solution that might require further dilution. The RN can determine if the physician must be notified, but the rate of infusion should not be decreased until further evaluation of the discomfort can be made.



vicky

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Both answers were spot on, thank you once again




 

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