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

Answer and Explanation

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.

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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.

A. The nurse applies a tourniquet to assess a vein. B. The nurse dons gloves before starting the IV. C. The nurse blows on the area cleansed with alcohol to dry it quickly D. The nurse cleans the area with an alcohol pad

Correct Answer is C

Explanation

A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.

B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.

C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.

D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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