IV IV Complications & Adverse Events 1 — Questions and Answers
Question 1: A patient develops redness, warmth, and swelling along the vein 2 cm proximal to the IV site. Which complication is most likely?
- Infiltration
- Phlebitis (Correct answer)
- Air embolism
- Thrombosis
Correct answer: Phlebitis
Phlebitis is characterized by redness, warmth, pain, and swelling along the course of the vein due to inflammation of the vessel wall.
Question 2: Which grading scale is most commonly used to assess the severity of phlebitis at a peripheral IV site?
- VIP Score
- Visual Infusion Phlebitis Scale
- Jackson Scale
- Both A and B (Correct answer)
Correct answer: Both A and B
Both the VIP (Visual Infusion Phlebitis) score and the Visual Infusion Phlebitis Scale are widely used tools to grade phlebitis from 0 (no signs) to 5 (advanced phlebitis).
Question 3: A nurse notices the IV infusion slowing and the area around the insertion site becoming cool, pale, and puffy. What is the most likely complication?
- Phlebitis
- Air embolism
- Infiltration (Correct answer)
- Catheter embolism
Correct answer: Infiltration
Infiltration occurs when IV fluid leaks into the surrounding tissue, causing coolness, pallor, and swelling at the site.
Question 4: What is the most immediate nursing action when extravasation of a vesicant medication is suspected?
- Apply warm compress and continue infusion
- Stop the infusion and leave the catheter in place to aspirate (Correct answer)
- Remove the catheter immediately and apply pressure
- Increase the infusion rate to dilute the vesicant
Correct answer: Stop the infusion and leave the catheter in place to aspirate
The immediate action for suspected vesicant extravasation is to stop the infusion and leave the catheter in place to aspirate residual drug before removal.
Question 5: Which of the following is a classic sign of catheter-related bloodstream infection (CRBSI)?
- Localized erythema only at insertion site
- Fever with no other identifiable source in a patient with a central line (Correct answer)
- Swelling and coolness at the IV site
- Decreased urine output
Correct answer: Fever with no other identifiable source in a patient with a central line
CRBSI classically presents as fever (and sometimes rigors) with no other identifiable infection source in a patient with a central venous catheter.
Question 6: A patient suddenly develops chest pain, dyspnea, hypotension, and a 'mill-wheel' heart murmur during IV therapy. Which complication should the nurse suspect?
- Pulmonary embolism
- Air embolism (Correct answer)
- Speed shock
- Fluid overload
Correct answer: Air embolism
Air embolism presents with sudden chest pain, dyspnea, hypotension, and the pathognomonic 'mill-wheel' murmur caused by air in the right heart.
IV IV Complications & Adverse Events 1
A patient develops redness, warmth, and swelling along the vein 2 cm proximal to the IV site.
Which complication is most likely?