RUHS, Jaipur, PB B.Sc Nursing Entrance-2022
Medical & Surgical Nursing
Easy
Which of the following complication arise if IV site is cool, pale and swollen and the solution is not infusing?
Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2022
Explanation
- The clinical presentation of a cool, pale, and swollen intravenous (IV) site where the infusion has stopped is a classic sign of infiltration.
- Infiltration occurs when the IV cannula dislodges from the vein, causing the IV fluid to leak into the surrounding subcutaneous tissue.
- The coolness is due to the infused fluid being at room temperature, which is cooler than body temperature. The pallor and swelling are caused by the fluid accumulation in the tissue, which increases pressure and reduces local blood flow.
Why Other Options Were Wrong
- Option A: Thrombosis involves a blood clot, which typically causes pain, redness (erythema), and warmth at the site due to the inflammatory response, not coolness and pallor.
- Option B: A local IV site infection presents with cardinal signs of inflammation, including redness, warmth, purulent drainage, and pain, which are opposite to the cool and pale signs given.
- Option D: Phlebitis is vein inflammation, characterized by warmth, redness, tenderness, and sometimes a palpable venous cord. The question describes a cool and pale site.
Related Visual
Clinical Relevance
- Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Identification of intravenous (IV) therapy complications based on clinical signs as background academic context rather than a clinical decision trigger.
- Prompt recognition of IV infiltration is a critical nursing skill to prevent tissue damage, nerve compression, and compartment syndrome.
- Nursing assessment of an IV site should be performed regularly (e.g., every 1-2 hours for adults) to check for patency and signs of complications.
- What if? If the infiltrated fluid was a vesicant medication like chemotherapy or vasopressors, the situation becomes an emergency called extravasation. It requires stopping the infusion, attempting to aspirate the drug, administering a specific antidote, and immediate physician notification, as it can lead to severe tissue necrosis.
How to Approach the Question
- First, analyze the keywords in the stem: 'cool', 'pale', 'swollen', and 'solution not infusing'. These are the defining clinical signs.
- This is an analytical question requiring you to match a set of symptoms to a specific medical complication.
- Systematically evaluate each option against the provided signs.
- Recall the pathophysiology of each complication. Infiltration involves fluid leaking into tissue, making it cool and swollen. Phlebitis, infection, and thrombosis are inflammatory or occlusive processes that cause warmth and redness.
- Eliminate options that contradict the key signs. 'Cool' and 'pale' directly contradict the 'warm' and 'red' signs associated with the other three options.
- Select the option that perfectly matches all the described signs.
Concept Tested & Keywords
- Concept Tested: Identification of intravenous (IV) therapy complications based on clinical signs.
- Stem keywords: IV site, cool, pale, swollen, solution not infusing, complication
- Lead-in keywords: Which
- Clinical cues: Cool, pale, and swollen IV site: Classic triad for infiltration.
- Clinical cues: Solution not infusing: Indicates obstruction or displacement from the vein.
Question ID
QLZiu-QgFEt5OnHrG0X5x3
Reference Book
E6 Nursing Fundamentals Taylor p. 801-803
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 74-76
Practise the full RUHS, Jaipur, PB B.Sc Nursing Entrance-2022
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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