An 87-year-old patient recovering from abdominal surgery has a continuous intravenous infusion to supply nutrients and antibiotics. What complication should you suspect when signs and symptoms of redness, warmth, and pain at the infusion site are reported?
Hematoma
Phlebitis
Speed Shock
Thrombosis
The Correct Answer is B
A. Hematoma: A hematoma typically results from bleeding into the tissue, causing swelling and bruising at the infusion site, but it doesn't usually cause warmth or pain in the same way as phlebitis.
B. Phlebitis: Phlebitis is inflammation of the vein, commonly caused by an IV catheter or medication, and it often presents with redness, warmth, pain, and swelling at the infusion site. It is the most likely complication here.
C. Speed Shock: Speed shock occurs when a medication or fluid is administered too rapidly, causing symptoms such as dizziness, chest tightness, and hypotension, not localized symptoms like redness and pain at the infusion site.
D. Thrombosis: Thrombosis refers to the formation of a blood clot within a vein, which can cause swelling, warmth, and discomfort but would also likely involve more significant blockage and would be associated with reduced blood flow, not just localized redness and pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Have the laboratory draw a blood sample for an erythrocyte sedimentation rate (ESR): ESR measures inflammation and is unrelated to hyperkalemia.
B. Restrict fluid intake: Fluid restriction is not appropriate for hyperkalemia unless specifically related to fluid overload or renal failure.
C. Obtain a 12-lead ECG: Hyperkalemia can cause life-threatening cardiac dysrhythmias such as peaked T waves, widened QRS complexes, or asystole. ECG monitoring is essential.
D. Administer potassium gluconate 40 mEq orally: This would worsen hyperkalemia and is contraindicated.
Correct Answer is A
Explanation
A. 0.9% sodium chloride: Normal saline (0.9% sodium chloride) is the standard solution that can be administered with blood products. It is isotonic and does not cause hemolysis or alter the structure of red blood cells.
B. Lactated Ringers solution: Lactated Ringers solution is not used with blood products due to the potential for hemolysis when calcium is present, which can interfere with the clotting cascade and affect blood cell integrity.
C. 5% dextrose/0.2% sodium chloride: Dextrose solutions should not be used with blood components, as they can cause red blood cells to hemolyze, leading to hemolysis and complications in transfusion.
D. 5% dextrose/0.45% sodium chloride: This solution contains dextrose, which can cause red blood cell hemolysis and should not be used with blood products.
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