Chitranjjan National Cancer Institute Kolkata - 2021
Medical & Surgical Nursing
Easy
A patient receiving IV fluids develops warm tenderness, erythema and pain at the site. The nurse suspect which of the following?
Appeared in: Chitranjjan National Cancer Institute Kolkata - 2021
Explanation
- The patient's symptoms—warmth, tenderness, erythema (redness), and pain—are the hallmark signs of inflammation.
- Phlebitis is defined as the inflammation of a vein's inner layer (the tunica intima).
- These signs are localized to the venipuncture site, indicating a local complication rather than a systemic one.
- The visual evidence in the image, showing redness at the IV site, further supports the diagnosis of phlebitis.
Why Other Options Were Wrong
- Option A: Fluid overload is a systemic complication, not a local one. Its signs include shortness of breath, crackles in the lungs, engorged neck veins, and widespread edema, not localized warmth and redness at the IV site.
- Option B: Sepsis is a life-threatening systemic infection. While a local infection at an IV site can lead to sepsis, the initial presentation described is purely local. Sepsis would involve systemic symptoms like fever, chills, tachycardia, and hypotension.
- Option D: Infiltration occurs when IV fluid leaks into the surrounding subcutaneous tissue. The key signs are coolness, pallor (blanched skin), and swelling, which are opposite to the warmth and redness seen in phlebitis.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Identification of complications related to intravenous (IV) therapy to guide bedside assessment, documentation, and the next nursing action.
- Regular and vigilant assessment of IV sites (at least every 1-2 hours for adults) is a critical nursing responsibility to ensure early detection and management of complications, preventing patient harm and interruption of therapy.
- Prompt identification of phlebitis and immediate removal of the IV catheter are essential to prevent the progression to more severe conditions like thrombophlebitis (inflammation with a blood clot) or systemic infection.
- What if? If the patient reported pain but the site was cool, pale, and swollen, the nurse should suspect infiltration. The immediate action is still to stop the infusion, but the follow-up care would involve applying a cold compress initially (to reduce swelling) and then possibly warm compresses later, depending on the type of fluid infiltrated.
How to Approach the Question
- First, analyze the patient's symptoms presented in the stem: warm tenderness, erythema, and pain.
- Note that the symptoms are localized to the IV site, which points towards a local complication.
- Evaluate each option against these localized, inflammatory signs.
- Rule out systemic complications like Fluid Overload and Sepsis, which present with body-wide symptoms (e.g., respiratory distress, fever, hypotension).
- Differentiate between the two most common local complications: Phlebitis (characterized by warmth and redness) and Infiltration (characterized by coolness and pallor).
- Conclude that the patient's symptoms directly match the classic definition of phlebitis.
Concept Tested & Keywords
- Concept Tested: Identification of complications related to intravenous (IV) therapy.
- Stem keywords: IV fluids, warm tenderness, erythema, pain, IV site
- Lead-in keywords: suspect which of the following
- Clinical cues: The combination of warmth, redness, and pain localized at an IV site is a classic triad for phlebitis.
Question ID
QAX_ajz2oeaRXR4iuCNodY
Reference Book
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 74-76
E6 Nursing Fundamentals Taylor p. 801-803
Practise the full Chitranjjan National Cancer Institute Kolkata - 2021
Attempt every question from this paper in a timed mock, then review the full solution for each one.
More Fluid and Electrolytes: Balance and Distribution Questions
- All are crystalloid solution; except:
- ECG of the patient is showing ST depression, Prominent U wave and inverted T wave. Which of the electrolyte imbalance present?
- A patient reports calcium loss. What is the nursing intervention?
- The principle of hemodialysis in which the water is moving under high pressure to an area of lower pressure is:
- Measurement of arterial blood gas shows pH: 7.2, PaCO2 : 70 mm Hg, HCO3: 27 mmol/L and PaO2: 59 mm Hg. Interpret this:
- Fluid volume deficit or hypovolemia describes the loss of
- A patient presents to the emergency department with a serum pH of 7.25, pCO2 of 40 mmHg, HCO3 of 22 mEq/L, sodium of 150 mEq/L, and chloride of 100 m…
- A 65-year-old patient is admitted to the hospital with a serum sodium level of 132 mmol/L. Despite being asymptomatic at admission, the patient begin…
- You are assessing a patient who is experiencing hyperventilation, resulting in a below-normal carbon dioxide (CO2) level. The patient is exhibiting s…
- A patient undergoes nasogastric suctioning for several days. Which electrolyte imbalance is most likely to occur due to this treatment?
More Chitranjjan National Cancer Institute Kolkata - 2021 Questions
- Warning signs of lung cancer include persistent cough, bloody sputum, dyspnea and which of the other following symptoms?
- At the time of diagnosis of Hodgkin's lymphoma, which of the following area is often involved?
- Which of the following is a malignant tumor of the connective tissue?
- Which of the following is suggested surgical intervention for Ca Prostate?
- Which type of cancer has poorest prognosis given below?
- Which of the following is the feature of benign tumor?
- The patient with cancer is receiving chemotherapy and develops thrombocytopenia The nurse identifies which intervention as the highest priority in th…
- In the patient with terminal lung cancer, the focus of nursing care is on which of the following nursing interventions?
- Mrs. Sharma with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the patient about this drug, the nurse should emphasize the…
- Kaposi's sarcoma is the type of cancer which is common in people with?