A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?

Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.

Choice A Reason:

"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.

Choice B Reason:

"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.

While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.

Choice C Reason:

"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.

Choice D Reason:

"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.