In a patient IV site shows redness, heat, tenderness, decrease flow rate, are the classical sign of?

Appeared in: NORCET 3 - 2022 (Shift-1)

Explanation

Phlebitis is the inflammation of a vein's inner layer, the tunica intima.
The classic signs of inflammation are redness (erythema), heat, tenderness/pain, and swelling, which directly match the symptoms described in the question.
The term 'phlebitis' is derived from Greek roots: 'phleb-' meaning vein and '-itis' meaning inflammation.
Inflammation and potential thrombus formation within the vein can narrow the lumen, leading to a decreased or stopped IV flow rate.

Option A: Infiltration is characterized by coolness, pallor (blanching), and swelling at the IV site, not redness and warmth.
Option C: An allergic reaction to an IV medication is typically a systemic response, causing symptoms like itching (pruritus), hives (urticaria), rash, and potentially respiratory distress or hypotension. It does not primarily present as localized warmth and tenderness at the insertion site.
Option D: Hypersensitivity is a severe, systemic allergic reaction (anaphylaxis). Its signs are more severe and widespread than the localized symptoms described. It is a medical emergency characterized by hypotension, bronchospasm, and angioedema.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of local complications of intravenous (IV) therapy to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform regular, systematic assessments of all IV sites to detect complications early, preventing progression to more severe conditions like thrombophlebitis, tissue damage, or infection.
Prompt identification and intervention (stopping the infusion, removing the cannula) are critical nursing responsibilities to minimize patient harm and preserve venous access for future therapy.
What if? If the site was cool, pale, and swollen with taut skin, the correct answer would be Infiltration. The key differentiating factor is the temperature and color of the skin at the site.

How to Approach the Question

First, identify the key assessment findings in the question: redness, heat, and tenderness.
Recognize that these are the cardinal signs of inflammation.
Analyze the options. 'Phlebitis' literally means inflammation (-itis) of a vein (phleb-).
Compare the signs with the known characteristics of the other options. Infiltration involves coolness and pallor. Allergic reactions are typically systemic.
Conclude that the signs of inflammation described in the stem directly correspond to the definition of phlebitis, making it the correct answer.

Concept Tested & Keywords

Concept Tested: Identification of local complications of intravenous (IV) therapy
Stem keywords: IV site, redness, heat, tenderness, decrease flow rate
Lead-in keywords: classical sign of
Negative lead-in flag: false

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 74-76

E6 Nursing Fundamentals Taylor p. 801-803

Practise the full NORCET 3 - 2022 (Shift-1)

Attempt every question from this paper in a timed mock, then review the full solution for each one.