NVS Staff Nurse - 2019
Medical & Surgical Nursing
Medium
A patient complains of pain and has redness with swelling at the site of IV site. What should a nurse do first?
Appeared in: NVS Staff Nurse - 2019
Explanation
- The patient's symptoms of pain, redness, and swelling are hallmark signs of an intravenous complication, most likely phlebitis or infiltration.
- The primary nursing principle in this situation is to prevent further harm. The infusion is the direct cause of the ongoing tissue irritation or damage.
- Therefore, the immediate and highest priority action is to stop the infusion and remove the IV cannula to halt the cause of the complication and prevent worsening of the injury.
- All other interventions, such as applying compresses or elevating the limb, are secondary actions performed only after the IV has been discontinued.
Why Other Options Were Wrong
- Option A: Applying a warm moist pack is a therapeutic measure to manage the symptoms of phlebitis, but it is not the first action. The source of the inflammation must be removed before initiating treatment.
- Option C: Continuing the infusion is contraindicated and dangerous. It would cause more fluid to leak into the tissues (infiltration) or further irritate the inflamed vein (phlebitis), leading to increased pain, swelling, and risk of severe tissue damage or infection.
- Option D: The problem is located at the patient's IV insertion site (the vein and surrounding tissue), not with the administration set. Changing the tubing and solution would not resolve the local complication and would waste time and resources.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Priority nursing action for IV site complications (phlebitis/infiltration) to guide bedside assessment, documentation, and the next nursing action.
- Prompt recognition and management of IV complications are fundamental nursing responsibilities that directly impact patient safety and comfort.
- Regularly assessing IV sites (at least every 1-2 hours for adults) is a standard of care to detect early signs of complications like phlebitis, infiltration, or infection.
- Failure to act quickly can lead to more severe complications, including tissue necrosis (death), nerve damage, or systemic infection (sepsis).
How to Approach the Question
- First, identify the clinical scenario presented in the question. Here, it's a patient with a problem at an IV site.
- Next, analyze the key signs and symptoms provided: 'pain', 'redness', and 'swelling'. Recognize these as classic indicators of IV complications like phlebitis or infiltration.
- The question asks for the 'first' action, which signals a priority-based question. In nursing, the first action is almost always to remove the source of the problem to prevent further harm.
- Evaluate the options based on this principle. Stopping the infusion and removing the cannula is the only option that directly addresses and halts the cause of the complication.
- Eliminate other options: Applying a warm pack is a treatment, not the first step. Continuing the infusion is harmful. Changing the tubing is irrelevant to the site-specific problem.
Concept Tested & Keywords
- Concept Tested: Priority nursing action for IV site complications (phlebitis/infiltration).
- Stem keywords: IV site, pain, redness, swelling
- Lead-in keywords: first
- Clinical cues: Signs of local IV complication (pain, redness, swelling) require immediate intervention.
- Negative lead-in flag: false
Question ID
QEAYrHOP3QOMsFNA9S7HX9
Reference Book
E6 Nursing Fundamentals Taylor p. 801-803
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 74-76
Practise the full NVS Staff Nurse - 2019
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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