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Practice 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 Choices:

Correct Answer:

Streak formation along the vein

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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This question is from ☑️Custom Pharmacology II class 62 Final Exam KL LM which contains 57 questions.

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From Exam
☑️Custom Pharmacology II class 62 Final Exam KL LM

57 Questions

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: ATI Exam(s)
  • Domain: RN ATI Pharmacology
  • Answer Choices: 5
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