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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This method is recommended because it is less painful, as the sides of the fingertips have fewer nerve endings compared to the pads or 'balls' of the fingers.
A. Avoiding the use of the thumbs is not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
B. Avoiding the use of the dominant hand's fingers are not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.
D. Using the ball of the finger is not recommended for blood glucose monitoring because it can be more painful and may lead to less blood flow, resulting in difficulty obtaining an adequate blood sample.
Correct Answer is C
Explanation
C. Dextrose 5% in water is a hypotonic solution that contains 5 grams of dextrose in each 100 mL of water. It provides free water without adding significant sodium, which helps to dilute the elevated sodium levels in hypernatremia. This solution is effective in correcting hypernatremia by promoting water movement from the intravascular space into the cells and extracellular space.
A. Albumin solutions are primarily used for volume expansion and to increase oncotic pressure in conditions like hypoalbuminemia or shock. They do not provide free water and are not typically used for treating hypernatremia.
B. Dextrose 10% in water is a hypertonic solution used primarily for providing calories and treating hypoglycemia. It does not correct hypernatremia because it does not significantly affect sodium levels or provide sufficient free water to dilute sodium.
D. Dextran 40 is a colloid solution that is used for volume expansion in hypovolemia or shock. It does not provide free water and is not indicated for correcting hypernatremia.
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