Question

A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Answer 1

Correct Answers:

Streak formation along the vein
Warmth at insertion site
Erythema at the insertion site

Rationale :

💎 Streak formation along the vein

💎 This finding indicates inflammation that tracks along the affected vein, a hallmark sign of phlebitis.

💎 The red streak forms because the vein’s endothelial lining is irritated, causing an inflammatory response that extends proximally.

💎 Clients often report tenderness and pain along the vein, reinforcing that the vein itself—not the surrounding tissue—is inflamed.

💎 Recognizing this early prevents complications such as thrombophlebitis or progression to localized infection.

💎 Warmth at the insertion site

💎 Warmth reflects increased blood flow to the inflamed area, which occurs when the vein wall becomes irritated.

💎 This is one of the classic signs of the body’s inflammatory process and strongly indicates phlebitis rather than infiltration (which is cool).

💎 Warmth typically appears alongside pain, swelling, and redness, creating the symptom cluster associated with phlebitis.

💎 Prompt reporting prevents worsening inflammation and allows for timely IV removal and comfort measures.

💎 Erythema at the insertion site

💎 Redness around the catheter site is an early and common indicator of vein inflammation.

💎 Erythema accompanies irritation from mechanical trauma, irritant solutions, or bacterial presence in the vein.

💎 When erythema occurs with tenderness and warmth, it strongly suggests phlebitis rather than infiltration or extravasation.

💎 The nurse should remove the IV, apply a warm compress, and document findings to prevent further tissue damage.

❌ Incorrect Option

❌ Damp dressing over the insertion site

❌ A damp or wet dressing usually indicates leakage or infiltration, not phlebitis.

❌ This finding is linked to fluid escaping the vein or loose tubing, not inflammation of the vein wall.

❌ Blistering around the insertion site

❌ Blisters suggest extravasation of a vesicant medication, not phlebitis.

❌ This is a sign of tissue damage, which is different from the inflammation seen in phlebitis.

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Answer 2

Correct Answers:

Apply the ointment in a thin line into the conjunctival sac.

Rationale :

🟦 Applying the ointment in a thin line into the conjunctival sac ensures the medication reaches the correct anatomical space for absorption.

🟦 The conjunctival sac holds the ointment in place, allowing even distribution across the ocular surface as the client blinks.

🟦 This method prevents contamination of the applicator tip and avoids touching the cornea, which could cause injury or infection.

🟦 Correct placement also minimizes blurred vision and maximizes the therapeutic effect of the antibiotic for treating bacterial conjunctivitis.

❌ Incorrect Options

❌ Wiping outer → inner canthus increases risk of spreading infection toward the nasolacrimal duct.

❌ Using a sterile glove is unnecessary; clean technique is sufficient for ointment application.

❌ Keeping the eye open 30 sec is unrealistic and not required for proper absorption.

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Answer 3

Correct Answers:

Have protamine available in case of overdose.

Rationale :

🟩 Protamine sulfate is the reversal agent for enoxaparin, a low-molecular-weight heparin, and must be available in case of bleeding or overdose.

🟩 Enoxaparin increases the risk of hemorrhage, so ensuring antidote availability is an essential safety action.

🟩 Protamine binds with enoxaparin to neutralize its anticoagulant effect and prevent life-threatening complications.

🟩 This instruction reinforces safe medication administration practices when handling anticoagulants.

❌ Incorrect Options

❌ Injecting enoxaparin into a large muscle is wrong; it must be given subcutaneously.

❌ Monitoring potassium is not required; enoxaparin affects bleeding, not potassium balance.

❌ Do not expel the air bubble; it creates an air lock to reduce bruising.

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Answer 4

Correct Answers:

Request that the surgeon prescribe a different antibiotic.

Rationale :

🟧 A history of anaphylaxis to penicillin places the client at increased risk for a cross-sensitivity reaction to cephalosporins such as cephalexin.

🟧 Administering cephalexin in this context could trigger a severe, potentially life-threatening hypersensitivity reaction.

🟧 The safest nursing action is to notify the surgeon and request an alternative antibiotic that does not pose cross-reactivity risks.

🟧 This protects the client from anaphylaxis and adheres to safe medication administration standards.

❌ Incorrect Options

❌ Confirming whether it was “real anaphylaxis” delays care and does not change the cross-risk.

❌ Administering the medication places the client in danger.

❌ Giving diphenhydramine is not adequate protection against true anaphylaxis.

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Answer 5

Correct Answers:

Valerian

Rationale :

🟪 Valerian is an herbal supplement known for its sedative and calming properties, often used for insomnia and anxiety.

🟪 When combined with CNS depressants, valerian increases the risk of excess sedation, impaired cognition, and respiratory depression.

🟪 Understanding herbal-drug interactions is vital because these supplements are not benign and can potentiate pharmacologic effects.

🟪 Clients taking CNS depressants should be advised to avoid valerian to prevent dangerous additive sedation.

❌ Incorrect Options

❌ Ginkgo biloba affects bleeding, not sedation.

❌ Black cohosh interacts hormonally, not with CNS depressants.

❌ Echinacea affects immune modulation, not sedation.

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Answer 6

Correct Answers:

6

Rationale :

Calculation

Medication available: 250 mg ÷ 5 mL = 50 mg per mL

Ordered dose: 300 mg ÷ 50 mg/mL = 6 mL

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Answer 7

Correct Answers:

Increase daily intake of foods high in potassium.

Rationale :

🔷 Hydrochlorothiazide is a thiazide diuretic that increases the excretion of sodium and water but also causes increased potassium loss, putting the client at risk for hypokalemia.

🔷 Increasing dietary potassium helps maintain normal neuromuscular and cardiac function, which are negatively affected when potassium is low.

🔷 Symptoms such as muscle weakness, fatigue, and arrhythmias can occur if potassium is not adequately replaced.

🔷 Teaching clients to consume potassium-rich foods such as bananas, oranges, potatoes, and spinach helps prevent adverse effects from this medication.

❌ Incorrect Options

❌ Take on an empty stomach — hydrochlorothiazide may cause GI upset; taking with food is recommended.

❌ Take at bedtime — this increases nocturia; thiazides should be taken in the morning.

❌ Muscle weakness is expected — it signals hypokalemia, which is dangerous, not expected.

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Answer 8

Correct Answers:

Watery diarrhea

Rationale :

🔶 Clindamycin carries a high risk for Clostridioides difficile (C. diff) infection, which presents with watery diarrhea, abdominal cramping, fever, and potential dehydration.

🔶 This complication reflects a severe antibiotic-associated colitis, which requires immediate medical attention to prevent progression to life-threatening pseudomembranous colitis.

🔶 Early reporting allows the provider to discontinue the medication and begin appropriate therapy, such as metronidazole or vancomycin.

🔶 Monitoring for stool changes is essential, as persistent diarrhea is a hallmark sign of toxic colon inflammation.

❌ Incorrect Options

❌ Nausea — a common and mild side effect, not urgent.

❌ Pruritus — may indicate mild hypersensitivity, but not emergent.

❌ Abdominal bloating — nonspecific and not diagnostic of serious reaction.

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Answer 9

Correct Answers:

31

Rationale :

Calculation

Total volume: 1000 mL

Time: 8 hr = 480 min

Drop factor: 15 gtt ÷ 1 mL

Formula:

1000 mL÷480 min=2.08 mL/min

2.08 mL/min×15 gtt/mL=31.25 gtt/min

Rounded: 31 gtt/min

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Answer 10

Correct Answers:

Expect to have insomnia while taking this medication.

Rationale :

🟣 Rifampin commonly causes orange discoloration of urine, sweat, tears, and saliva due to the pigmentation of the medication itself.

🟣 This harmless yet noticeable effect must be taught in advance so clients do not mistake it for blood or an adverse reaction.

🟣 Rifampin is a first-line antituberculosis medication, and adherence is essential for preventing drug resistance and treatment failure.

🟣 The discoloration may also permanently stain soft contact lenses, so clients should be advised accordingly.

❌ Incorrect Options

❌ Take with meals — rifampin should be taken 1 hour before or 2 hours after meals to improve absorption.

❌ Expect insomnia — rifampin does not cause this effect.

❌ PPD test improves in 3 months — PPD results do not reflect treatment response.

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QLexNursing

1 :
A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

2 :
A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

3 :
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell, the client can increase sedation in clients who take CNS depressant medications?

6 :
A nurse is preparing to administer amoxicillin 300 mg PO. The amount available is amoxicillin oral solution 250 mg/5 ml. How many ml should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL

7 :
A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide. Which of the following information should the nurse include in the teaching?

8 :
A nurse is collecting data from a client who has a prescription for oral clindamycin hydrochloride. Which of the following findings should the nurse immediately report to the provider?

10 :
A nurse is reinforcing discharge teaching with a client who has pulmonary tuberculosis and is to start taking rifampin. Which of the following information should the nurse include?

QLexNursing

1 : A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

2 : A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

3 : A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

5 : A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell, the client can increase sedation in clients who take CNS depressant medications?

6 : A nurse is preparing to administer amoxicillin 300 mg PO. The amount available is amoxicillin oral solution 250 mg/5 ml. How many ml should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL

7 : A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide. Which of the following information should the nurse include in the teaching?

8 : A nurse is collecting data from a client who has a prescription for oral clindamycin hydrochloride. Which of the following findings should the nurse immediately report to the provider?

10 : A nurse is reinforcing discharge teaching with a client who has pulmonary tuberculosis and is to start taking rifampin. Which of the following information should the nurse include?

1 :
A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

2 :
A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

3 :
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell, the client can increase sedation in clients who take CNS depressant medications?

6 :
A nurse is preparing to administer amoxicillin 300 mg PO. The amount available is amoxicillin oral solution 250 mg/5 ml. How many ml should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL

7 :
A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide. Which of the following information should the nurse include in the teaching?

8 :
A nurse is collecting data from a client who has a prescription for oral clindamycin hydrochloride. Which of the following findings should the nurse immediately report to the provider?

10 :
A nurse is reinforcing discharge teaching with a client who has pulmonary tuberculosis and is to start taking rifampin. Which of the following information should the nurse include?