Patient complains of pain and has redness with swelling at the site of IV. The nurse must

OSSSC Nursing Officer-2021

Medical Surgical Nursing

Medium

Appeared in: OSSSC Nursing Officer-2021

Explanation

The patient's signs (pain, redness, swelling) are characteristic of phlebitis, an inflammation of the vein.
The priority nursing action for phlebitis or infiltration is to immediately stop the infusion and remove the cannula.
This action prevents further administration of irritating fluid and removes the mechanical source of irritation, thereby minimizing further damage to the vein and surrounding tissue.
All other interventions are secondary and should only be performed after the IV has been discontinued.

Option B: Starting nasal oxygen is irrelevant to the clinical problem. The patient's symptoms are localized to the IV site and do not indicate respiratory compromise.
Option C: Changing the tubing and solution does not address the problem at the insertion site, which is already inflamed or infiltrated. Continuing to use the compromised site would worsen the injury.
Option D: Applying a warm pack is a subsequent therapeutic measure for phlebitis, not the initial action. The primary goal is to first remove the cause of the inflammation.

Clinical Relevance

Nursing practice connection: Use the key finding related to Management of Intravenous (IV) Therapy Complications to guide bedside assessment, documentation, and the next nursing action.
Prompt identification and management of IV complications are critical patient safety responsibilities for nurses. Failure to act can lead to severe outcomes like thrombophlebitis, tissue necrosis, or systemic infection (sepsis).
Nurses must perform and document routine assessments of all vascular access sites at least every hour for any signs of complications, as per Infusion Nurses Society (INS) standards.
What if? If the patient's IV site was swollen, pale, and cool to the touch instead of red and warm, the complication would be infiltration. The priority action remains the same (stop infusion, remove cannula), but the subsequent intervention would be to apply a cool compress, not a warm one, and elevate the limb.

How to Approach the Question

First, analyze the patient's symptoms presented in the stem: pain, redness, and swelling at an IV site.
Recognize these as classic signs of a local IV complication, most likely phlebitis.
Recall the principles of nursing priority-setting. The first step is always to remove the source of harm to prevent further injury.
Evaluate the options based on this principle. Stopping the infusion and removing the cannula is the only option that directly addresses and removes the cause of the problem.
Differentiate between initial actions and subsequent comfort measures. Applying a warm pack is a correct treatment for phlebitis but is not the first priority.

Concept Tested & Keywords

Concept Tested: Management of Intravenous (IV) Therapy Complications
Stem keywords: pain, redness, swelling, IV site
Lead-in keywords: must
Clinical cues: The combination of pain, redness, and swelling at an IV site strongly indicates an acute complication like phlebitis or infiltration, requiring immediate action.

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

E6 Nursing Fundamentals Taylor p. 801-803