The nurse receives report on 4 clients. Which client should the nurse assess first?

Question

Quizplus · Accepted Answer

11ecbb05_cbdb_e8b1_b433_51ad09eedd6c_MD0009_00 Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. (Option A) Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief. (Option B) Evidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection. (Option C) Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This therapy is expected. Educational objective: Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis.

The Nurse Receives Report on 4 Clients