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. Provide oxygen at 2 L per nasal cannula: Although oxygen might be helpful later, the patient currently has a good oxygen saturation (95%). The priority is to ease breathing and reduce fluid accumulation in the lungs.

B. Provide a urinal and encourage the patient to void: While voiding might help reduce fluid volume, repositioning the patient to improve breathing is more urgent.

C. Place the patient in a high Fowler position: This position maximizes lung expansion, improves oxygenation, and helps alleviate dyspnea caused by fluid overload.

D. Lay the patient flat in bed to listen to bowel sounds: Placing the patient flat can worsen pulmonary symptoms by allowing fluid to shift toward the lungs.

A. Skeletal muscle weakness B. Decreased deep-tendon reflexes C. Tingling of the lips D. Hypoactive bowel sounds

Correct Answer is C

Explanation

A. Skeletal muscle weakness: This is more commonly seen with hypercalcemia, not hypocalcemia. Hypocalcemia typically causes neuromuscular irritability, which manifests as muscle spasms rather than weakness.

B. Decreased deep-tendon reflexes: This is more commonly seen with hypercalcemia. Hypocalcemia typically increases neuromuscular irritability and can cause hyperactive reflexes.

C. Tingling of the lips: This is a classic sign of hypocalcemia, as low calcium levels can lead to neuromuscular excitability, which can cause sensations like tingling (paresthesia) around the lips and fingers.

D. Hypoactive bowel sounds: Hypocalcemia typically increases bowel motility, which can lead to hyperactive bowel sounds, not hypoactive bowel sounds.

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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

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