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?

Correct Answer: A

Rationale: The correct answer is A: Grade 3 phlebitis at IV site. This is because the presence of a red streak along the vein path and a palpable 4-cm venous cord are classic signs of phlebitis, indicating inflammation of the vein. Grade 3 phlebitis specifically refers to visible redness, pain, and swelling along the vein. Phlebitis can be caused by mechanical irritation, chemical irritation, or infection. It is important to document this finding accurately to ensure appropriate treatment and monitoring. Summary of other choices: B: Infection at IV site - While infection can cause phlebitis, the red streak and venous cord are more indicative of inflammation rather than infection. C: Thrombosed area at IV site - Thrombosis involves the formation of a blood clot in the vein, which would present differently than the red streak and venous cord. D: Infiltration at IV site - Infiltration

Correct Answer: C

Rationale: The correct answer is C: "Rise slowly when you change position from lying to sitting or sitting to standing." Rationale: 1. Antipsychotics and beta-blockers can both cause orthostatic hypotension, a drop in blood pressure when changing positions. 2. The combination of these medications increases the risk of orthostatic hypotension. 3. Instructing the client to rise slowly helps prevent dizziness, lightheadedness, or potential falls associated with orthostatic hypotension. Summary: A: Slow breathing techniques are not directly related to the side effects of these medications. B: While diet and exercise are important, they do not address the specific side effects of antipsychotics and beta-blockers. D: Sunscreen and sun exposure are not relevant to the side effects of these medications.

Correct Answer: B

Rationale: The correct answer is B because not using the walker poses a safety risk for the client, leading to falls or injuries. Immediate nursing intervention is needed to assess and address the client's refusal to use the walker. Choice A is incorrect because eating 80% of meals shows good appetite and does not require immediate intervention. Choice C is incorrect as watching TV with others is a social activity and not a cause for concern. Choice D is incorrect as wanting to wear own clothing is a normal preference and does not pose a risk to the client's safety.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates therapeutic communication by expressing empathy and encouraging the son to share his feelings. By acknowledging his emotions, the nurse can establish trust and build a rapport with the son, which is crucial in this sensitive situation. Option B is incorrect as it focuses on medical facts rather than addressing the emotional needs of the son. Option C is incorrect as it lacks empathy and may come off as dismissive. Option D is incorrect as it jumps to a solution without addressing the son's emotional state. In summary, option A is the best response as it prioritizes the son's emotional needs and allows for effective communication.

Correct Answer: B

Rationale: The correct answer is B: absorbed through the skin. Transdermal medications are applied to the skin and absorbed into the bloodstream. This route bypasses the digestive system and first-pass metabolism, providing a consistent drug level. Choices A, C, and D are incorrect as they describe different routes of drug administration that are not associated with the transdermal route.