NCLEX-RN® Question of the Day: Pain at port insertion site

Today’s NCLEX-RN® question of the day focuses on a patient who feels pain at the insertion site during infusion of a medication.

During the infusion of a medication through an implanted port, a client reports pain at the insertion site. Which of these complications should the nurse suspect to be the most likely cause of the pain?

A. Extravasation

B. Chylothorax

C. Catheter migration

D. Infection

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The correct answer to today’s NCLEX-RN® Question is…

A. Extravasation

Rationale: Pain or a strange sensation at the insertion site during the infusion of a medication is an indication that extravasation has occurred. If the tip of the catheter migrates and is no longer in the superior vena cava the client will often report ear, neck, or shoulder pain. Clinical manifestations of an infection would include redness, swelling, and tenderness at the insertion site.

Major Takeaway

Pain or a strange sensation at the insertion site during the infusion of a medication is an indication that extravasation has occurred.

Incorrect Answer Explanations

B. Chylothorax

Rationale: Injury to the thoracic duct could cause a chylothorax (leakage of lymph fluid leaks into the thoracic cavity), but this is not the most likely explanation.

C. Catheter migration

Rationale: If the tip of the catheter migrates and is no longer in the superior vena cava, the client will often report ear, neck, or shoulder pain, but not pain at the insertion site.

D. Infection

Rationale: Clinical manifestations of an infection would include redness, swelling, and tenderness at the insertion site, but this is not the most likely explanation.

Reference

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M. & Bucher, L. (2017). Medical-surgical nursing: Assessment and management of clinical problems (10th ed.). St. Louis, MO: Elsevier Mosby.

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