During a clinical rotation on an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool, blanched and slightly swollen. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?

Infiltration

Local inflammation

Thrombophlebitis

Phlebitis

Answer and Explanation

The Correct Answer is A

A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.

B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.

C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.

D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.

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Correct Answer is D

Explanation

D. Administering the injection in the love handles, 2 inches from the umbilicus. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.

A. Enoxaparin should not be transferred into another syringe unless specifically instructed by the manufacturer or pharmacy guidelines. Pre-filled syringes are designed to deliver the correct dose accurately and safely.

B. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.

C. A 30-degree angle is too shallow for subcutaneous injections and may result in the medication being deposited too close to the skin surface, potentially causing irritation or affecting absorption.

A. every 5 hours B. once per shift C. hourly D. once a day

Correct Answer is C

Explanation

C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.

A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.

B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.

D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.

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Naxlex Comprehensive Predictor Exams

A nurse observes a newly licensed nurse administer enoxaparin subcutaneously using a pre- filled syringe. Which of the following indicates appropriate medication administration?

Correct Answer is D

Explanation

The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:

Correct Answer is C

Explanation

If the nurse needs to administer a 2 mL injection what size syringe is most appropriate to use?

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