Review Complications of Intravenous therapy

Blood and Cardiovascular Disorders > Medical Surgical

Exam Review

Complications of Intravenous therapy

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Question 1:

A nurse is assessing a client who has an IV catheter in place for fluid administration. The nurse observes swelling, redness, and warmth around the insertion site. Which complication of IV therapy should the nurse suspect?

A. Phlebitis B. Infiltration C. Fluid overload D. Air embolism

Answer and Explanation

Choice A:

This choice is correct. The client's symptoms of swelling, redness, and warmth around the insertion site are indicative of phlebitis, which is inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.

Choice B:

This choice is incorrect because infiltration refers to the inadvertent administration of IV fluid into the surrounding tissues, causing swelling and coolness around the insertion site.

Choice C:

This choice is incorrect because fluid overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and bounding pulse, not local symptoms around the IV site.

Choice D:

This choice is incorrect because air embolism occurs when air enters the vascular system, leading to symptoms such as dyspnea, cyanosis, and chest pain, rather than localized symptoms at the insertion site.

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Question 2:

A client receiving IV medication complains of sudden chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A. Phlebitis B. Infiltration C. Fluid overload D. Air embolism

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis and infiltration typically do not cause chest pain, dyspnea, and tachycardia.

Choice B:

This choice is incorrect because infiltration is associated with localized symptoms around the IV site, not systemic symptoms like chest pain and dyspnea.

Choice C:

This choice is incorrect because fluid overload may cause respiratory distress and tachycardia, but it is not typically associated with sudden chest pain.

Choice D:

This choice is correct. The client's symptoms of sudden chest pain, dyspnea, and tachycardia are potential signs of an air embolism, which occurs when air enters the vascular system through the IV catheter and can lead to serious respiratory and cardiac complications.

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Question 3:

A client receiving IV fluids complains of a cool sensation around the insertion site, and the nurse observes swelling and blanching of the skin. Which complication of IV therapy should the nurse suspect?

A. Phlebitis B. Infiltration C. Fluid overload D. Catheter occlusion

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not blanching of the skin.

Choice B:

This choice is correct. The client's symptoms of a cool sensation, swelling, and blanching of the skin are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

Choice C:

This choice is incorrect because fluid overload is not associated with local symptoms around the insertion site.

Choice D:

This choice is incorrect because catheter occlusion may affect the IV flow rate, but it does not typically cause the symptoms described by the client.

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Question 4:

A client receiving IV fluids suddenly experiences shortness of breath, crackles in the lungs, and jugular vein distention. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A. Phlebitis B. Infiltration C. Fluid overload D. Catheter occlusion

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis and infiltration are not associated with symptoms of shortness of breath, crackles in the lungs, and jugular vein distention.

Choice B:

This choice is incorrect because infiltration typically does not cause respiratory symptoms like shortness of breath and crackles in the lungs.

Choice C:

This choice is correct. The client's symptoms of shortness of breath, crackles in the lungs (rales), and jugular vein distention are potential signs of fluid overload, which occurs when there is an excessive volume of IV fluids administered.

Choice D:

This choice is incorrect because catheter occlusion does not cause respiratory symptoms like those described by the client.

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Question 5:

A nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?

A. Changing the IV tubing every 24 hours B. Administering antibiotics prophylactically C. Keeping the IV bag above the level of the heart D. Using a large-gauge catheter

Answer and Explanation

Choice A:

This choice is correct. Changing the IV tubing every 24 hours is a recommended intervention to reduce the risk of catheter-related bloodstream infections (CRBSIs) by minimizing the accumulation of microorganisms in the tubing.

Choice B:

This choice is incorrect because administering antibiotics prophylactically is not a standard practice for preventing CRBSIs, and it can contribute to antibiotic resistance.

Choice C:

This choice is incorrect because keeping the IV bag above the level of the heart is a technique used to regulate IV flow rate, but it is not specifically related to preventing CRBSIs.

Choice D:

This choice is incorrect because using a large-gauge catheter is not a preventive measure for CRBSIs. The appropriate catheter size should be based on the client's clinical condition and the prescribed therapy.

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Question 6:

A client receiving IV medications develops a painful, warm, and red streak along the arm near the IV site. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A. Phlebitis B. Infiltration C. Thrombophlebitis D. Fluid overload

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis typically presents with redness and warmth around the insertion site, but it does not cause a painful, red streak along the arm.

Choice B:

This choice is incorrect because infiltration is characterized by swelling and blanching of the skin near the IV site, not a painful, red streak.

Choice C:

This choice is correct. The client's symptoms of a painful, warm, and red streak along the arm near the IV site are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot.

Choice D:

This choice is incorrect because fluid overload is not associated with a painful, warm, and red streak along the arm.Questions

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Question 7:

A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

A. The client prefers IV therapy over oral fluids. B. The client has a history of IV drug use. C. The client is unable to tolerate oral intake. D. The client's family requested IV therapy.

Answer and Explanation

Choice A:

This choice is incorrect because the client's preference for IV therapy over oral fluids is not a valid indication for initiating IV therapy. Clinical indications should guide the decision, not personal preferences.

Choice B:

This choice is incorrect because a history of IV drug use does not automatically indicate a need for IV therapy for dehydration. The client's current condition and clinical status should determine the need for IV fluids.

Choice C:

This choice is correct. In cases of severe dehydration where the client is unable to tolerate oral intake, IV therapy is essential to provide rapid rehydration and restore fluid and electrolyte balance.

Choice D:

This choice is incorrect because the family's request alone is not a sufficient indication for initiating IV therapy. The decision should be based on the client's clinical condition and medical needs.

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Question 8:

A client with a history of heart failure is receiving IV fluids. The nurse should closely monitor the client for which potential complication?

A. Infiltration B. Phlebitis C. Fluid overload D. Air embolism

Answer and Explanation

Choice A:

This choice is incorrect because infiltration is not directly related to the client's history of heart failure.

Choice B:

This choice is incorrect because phlebitis is not specifically associated with heart failure but rather with irritants in the IV solution or mechanical trauma.

Choice C:

This choice is correct. Clients with a history of heart failure are at an increased risk of fluid overload due to their compromised cardiac function. Monitoring for signs of fluid overload, such as dyspnea, jugular vein distention, and peripheral edema, is essential during IV therapy.

Choice D:

This choice is incorrect because an air embolism is not directly related to the client's history of heart failure.

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Question 9:

A client receiving IV antibiotics develops sudden onset dyspnea, chest pain, and cyanosis. The nurse should suspect which complication of IV therapy?

A. Phlebitis B. Infiltration C. Fluid overload D. Pulmonary embolism

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis does not present with symptoms of dyspnea, chest pain, and cyanosis.

Choice B:

This choice is incorrect because infiltration does not cause sudden onset dyspnea, chest pain, and cyanosis. Infiltration involves localized symptoms around the insertion site.

Choice C:

This choice is incorrect because fluid overload does not typically cause sudden onset dyspnea, chest pain, and cyanosis.

Choice D:

This choice is correct. The client's symptoms of sudden onset dyspnea, chest pain, and cyanosis are indicative of a pulmonary embolism, which occurs when a blood clot travels to the lungs. This can be a life-threatening complication of IV therapy, especially in clients receiving antibiotics who are at higher risk for clot formation.

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Question 10:

A nurse is preparing to administer an IV medication to a client. Which action is essential to prevent complications during the medication administration?

A. Administering the medication rapidly to ensure a quick effect. B. Diluting the medication with a large volume of IV fluid. C. Checking the client's allergies and medication compatibility. D. Using a smaller gauge IV catheter for the medication infusion.

Answer and Explanation

Choice A:

This choice is incorrect because administering the medication rapidly is not necessarily essential and can increase the risk of complications. Medications should be administered at the appropriate rate to prevent adverse effects.

Choice B:

This choice is incorrect because diluting the medication with a large volume of IV fluid may be unnecessary and may slow down the administration without specific indications.

Choice C:

This choice is correct. Checking the client's allergies and medication compatibility is essential to prevent adverse reactions and complications. Ensuring that the prescribed medication is appropriate for the client and does not interact negatively with other medications or allergies is crucial.

Choice D:

This choice is incorrect because the choice of IV catheter size depends on the medication's compatibility and viscosity, not just using a smaller gauge catheter for all medication infusions.

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Question 11:

A nurse is caring for a client receiving IV fluids and observes the client experiencing chills, fever, and elevated heart rate. The nurse should suspect which complication of IV therapy?

A. Infiltration B. Phlebitis C. Fluid overload D. Sepsis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration is not typically associated with chills, fever, and an elevated heart rate.

Choice B:

This choice is incorrect because phlebitis may cause local symptoms at the IV site but is not generally associated with systemic symptoms like fever and chills.

Choice C:

This choice is incorrect because fluid overload does not cause fever and chills but rather manifests as symptoms like dyspnea, edema, and increased blood pressure.

Choice D:

This choice is correct. The client's symptoms of chills, fever, and elevated heart rate are indicative of sepsis, a serious infection that can occur as a complication of IV therapy. Sepsis can develop if bacteria enter the bloodstream through the IV catheter and lead to a systemic inflammatory response.

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Question 12:

A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client's vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?

A. Infiltration B. Phlebitis C. Fluid overload D. Anaphylaxis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration is not typically associated with symptoms of chest pain, difficulty breathing, decreased blood pressure, and weak pulse.

Choice B:

This choice is incorrect because phlebitis does not cause sudden onset chest pain, difficulty breathing, decreased blood pressure, and weak pulse.

Choice C:

This choice is incorrect because fluid overload is not associated with symptoms like chest pain and decreased blood pressure. It may cause elevated blood pressure due to increased fluid volume.

Choice D:

This choice is correct. The client's symptoms of sudden chest pain, difficulty breathing, decreased blood pressure, and weak pulse are indicative of anaphylaxis, a severe allergic reaction. Anaphylaxis can occur in response to an allergen in the IV fluid or medication and can be life-threatening if not treated promptly.

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Question 13:

A client with chronic kidney disease is receiving IV therapy with a potassium-containing solution. The nurse should carefully monitor the client for which complication?

A. Hypokalemia B. Hyperkalemia C. Hypocalcemia D. Hyponatremia

Answer and Explanation

Choice A:

This choice is incorrect because receiving a potassium-containing solution is not associated with hypokalemia, but rather with the risk of hyperkalemia due to the increased potassium intake.

Choice B:

This choice is correct. Clients with chronic kidney disease are at risk of hyperkalemia, and receiving a potassium-containing solution through IV therapy can further elevate potassium levels.

Choice C:

This choice is incorrect because IV therapy with a potassium-containing solution is not related to hypocalcemia.

Choice D:

This choice is incorrect because IV therapy with a potassium-containing solution is not associated with hyponatremia.Questions

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Question 14:

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes swelling, coolness, and pallor around the insertion site. The infusion has slowed, and the client reports discomfort. Which complication of IV therapy should the nurse suspect?

A. Phlebitis B. Infiltration C. Fluid overload D. Air embolism

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not coolness and pallor.

Choice B:

This choice is correct. The client's symptoms of swelling, coolness, and pallor around the insertion site, along with a slowed infusion and discomfort, are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

Choice C:

This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.

Choice D:

This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as swelling and coolness around the IV site.

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Question 15:

A nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

A. Infiltration B. Phlebitis C. Fluid overload D. Extravasation

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not puncturing the vein. Burning pain is not typically associated with infiltration.

Choice B:

This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not fluid leakage and burning pain.

Choice C:

This choice is incorrect because fluid overload is not related to the puncture of the vein and leakage of IV fluid. Symptoms of fluid overload include dyspnea, elevated blood pressure, and jugular vein distention.

Choice D:

This choice is correct. The nurse should suspect extravasation, which occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture. Burning pain and discomfort at the insertion site are common symptoms of extravasation.

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Question 16:

A client receiving chemotherapy through an IV complains of pain, burning, and swelling around the IV site. The nurse notices the skin turning red and blistering. Which complication of IV therapy should the nurse suspect?

A. Phlebitis B. Infiltration C. Fluid overload D. Extravasation

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.

Choice B:

This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.

Choice C:

This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.

Choice D:

This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.

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Question 17:

A nurse is caring for a client with an IV catheter in place for fluid administration. The nurse observes the client's arm is edematous, and the skin feels cool to the touch. The infusion is sluggish, and the client reports discomfort at the site. Which complication of IV therapy should the nurse suspect?

A. Phlebitis B. Infiltration C. Fluid overload D. Air embolism

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not edema and coolness.

Choice B:

This choice is correct. The client's symptoms of edema, coolness, sluggish infusion, and discomfort at the site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

Choice C:

This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.

Choice D:

This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as edema and coolness around the IV site.

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Question 18:

A client receiving IV therapy complains of pain and burning at the insertion site. The nurse notices the skin turning red and becoming tender. Which action should the nurse take first?

A. Stop the IV infusion immediately. B. Elevate the arm to promote venous return. C. Apply a warm compress to the site for comfort. D. Administer a prescribed analgesic.

Answer and Explanation

Choice A:

This choice is correct. The client's symptoms of pain, burning, redness, and tenderness at the insertion site are indicative of a potential complication, such as phlebitis or infiltration. The nurse should stop the IV infusion immediately to prevent further damage.

Choice B:

This choice is incorrect because elevating the arm may not address the underlying complication of phlebitis or infiltration.

Choice C:

This choice is incorrect because applying a warm compress is not the priority. The nurse should first stop the infusion to prevent complications.

Choice D:

This choice is incorrect because administering an analgesic may provide temporary relief, but it does not address the potential complication causing the client's symptoms. The nurse should first stop the IV infusion to assess the site and determine appropriate interventions.Questions

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Question 19:

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes redness, warmth, and swelling around the insertion site, and the client reports tenderness and pain. Which complication of IV therapy should the nurse suspect?

A. Infiltration B. Extravasation C. Phlebitis D. Air embolism

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not redness, warmth, and tenderness around the insertion site.

Choice B:

This choice is incorrect because extravasation occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture, but it does not present with redness and swelling.

Choice C:

This choice is correct. The client's symptoms of redness, warmth, swelling, tenderness, and pain around the insertion site are indicative of phlebitis, which is the inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.

Choice D:

This choice is incorrect because an air embolism is not associated with symptoms of phlebitis, such as redness and swelling around the IV site.

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Question 20:

A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

A. Applying a warm compress to the IV site. B. Limiting the use of the affected arm for IV insertion. C. Avoiding the use of a tourniquet during IV insertion. D. Selecting a small-gauge catheter for the IV insertion.

Answer and Explanation

Choice A:

This choice is incorrect because applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.

Choice B:

This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.

Choice C:

This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.

Choice D:

This choice is incorrect because selecting a small-gauge catheter is not the primary intervention to prevent thrombophlebitis in a client with a history of DVT. The choice of catheter size should be based on the client's clinical needs and vein condition.

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Question 21:

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication?

A. Infiltration B. Phlebitis C. Fluid overload D. Thrombophlebitis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with chest pain, dyspnea, and tachycardia.

Choice B:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with chest pain, dyspnea, and tachycardia.

Choice C:

This choice is incorrect because fluid overload does not typically cause chest pain, dyspnea, and tachycardia but rather manifests as symptoms such as elevated blood pressure, jugular vein distention, and edema.

Choice D:

This choice is correct. The client's symptoms of chest pain, dyspnea, and tachycardia are potential signs of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can become dislodged and travel to the lungs, leading to a pulmonary embolism, which presents with chest pain and dyspnea.

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Question 22:

A nurse is caring for a client with a peripheral IV catheter in place. The client complains of tenderness and a palpable, cord-like structure along the vein. The nurse should suspect which complication of IV therapy?

A. Infiltration B. Phlebitis C. Fluid overload D. Thrombophlebitis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration is characterized by swelling, coolness, and pallor around the insertion site, not a palpable, cord-like structure along the vein.

Choice B:

This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not a palpable, cord-like structure.

Choice C:

This choice is incorrect because fluid overload is not associated with a palpable, cord-like structure along the vein . It may cause generalized edema and increased blood pressure.

Choice D:

This choice is correct. The client's symptoms of tenderness and a palpable, cord-like structure along the vein are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The palpable cord-like structure is likely a thrombus within the vein.

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Question 23:

A client receiving IV therapy develops a fever, chills, and malaise. The nurse notices red streaks along the vein path. Which complication of IV therapy should the nurse suspect?

A. Infiltration B. Phlebitis C. Sepsis D. Thrombophlebitis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with fever, chills, and malaise.

Choice B:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, not red streaks along the vein path.

Choice C:

This choice is correct. The client's symptoms of fever, chills, malaise, and red streaks along the vein path are indicative of sepsis, which is a severe infection that can occur as a complication of IV therapy. Red streaks along the vein path may indicate the spread of infection along the vein.

Choice D:

This choice is incorrect because thrombophlebitis does not typically present with symptoms of fever, chills, and malaise. It is associated with tenderness and a palpable, cord-like structure along the vein.Questions

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Question 24:

A nurse is caring for a client with an IV catheter in place for medication administration. The client reports tenderness, redness, and warmth around the insertion site. The nurse observes purulent drainage at the site. Which complication of IV therapy should the nurse suspect?

A. Infiltration B. Phlebitis C. Infection D. Thrombophlebitis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with purulent drainage and redness.

Choice B:

This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, but it does not cause purulent drainage.

Choice C:

This choice is correct. The client's symptoms of tenderness, redness, warmth, and purulent drainage around the insertion site are indicative of an infection, which can occur as a complication of IV therapy if bacteria enter the bloodstream through the catheter.

Choice D:

This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.

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Question 25:

A client receiving IV fluids develops a fever, tachycardia, and hypotension. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A. Infiltration B. Phlebitis C. Fluid overload D. Sepsis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, tachycardia, and hypotension.

Choice B:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, tachycardia, and hypotension.

Choice C:

This choice is incorrect because fluid overload is not associated with symptoms of fever, tachycardia, and hypotension. It is characterized by symptoms such as dyspnea and edema.

Choice D:

This choice is correct. The client's symptoms of fever, tachycardia, and hypotension are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.

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Question 26:

A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. The nurse should suspect which complication of IV therapy?

A. Infiltration B. Phlebitis C. Infection D. Thrombophlebitis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with purulent drainage and redness.

Choice B:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause purulent drainage.

Choice C:

This choice is correct. The client's symptoms of pain, redness, and purulent drainage at the IV site are indicative of an infection, which can occur as a complication of IV therapy, especially in clients with diabetes who may have compromised immune systems.

Choice D:

This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.

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Question 27:

A nurse is assessing a client receiving IV fluids and notes the presence of fever, chills, and confusion. The client's blood pressure is low, and the skin appears mottled. The nurse should recognize these symptoms as potential signs of which complication?

A. Infiltration B. Phlebitis C. Fluid overload D. Sepsis

Answer and Explanation

Choice A:

Choice B:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, confusion, and low blood pressure.

Choice C:

This choice is incorrect because fluid overload is not associated with symptoms of fever, chills, and confusion. It may cause elevated blood pressure and edema.

Choice D:

This choice is correct. The client's symptoms of fever, chills, confusion, low blood pressure, and mottled skin are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.

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Question 28:

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

A. Infiltration B. Phlebitis C. Thrombophlebitis D. Sepsis

Answer and Explanation

Choice A:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with warmth and swelling along the vein path.

Choice B:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause tenderness, warmth, and swelling along the vein path.

Choice C:

This choice is correct. The client's symptoms of tenderness, warmth, and swelling along the vein path are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can cause obstruction along the vein path, leading to the symptoms described by the client.

Choice D:

This choice is incorrect because sepsis typically presents with systemic symptoms like fever, chills, and confusion, not localized symptoms along the vein path.Questions

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Question 29:

A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?

A. Administer the medication as prescribed. B. Withhold the medication and notify the healthcare provider. C. Ask the client to rate the severity of the itchiness. D. Administer an antihistamine before giving the medication.

Answer and Explanation

Choice A:

This choice is incorrect because administering the medication as prescribed may exacerbate the allergic reaction and is not safe without further assessment and medical guidance.

Choice B:

This choice is correct. The client's statement about being allergic to penicillin and experiencing itchiness in the throat suggests a potential allergic reaction. The nurse should withhold the medication and promptly notify the healthcare provider to assess the client's allergic response and determine an alternative course of action.

Choice C:

This choice is not the priority action. While assessing the severity of the itchiness is important, the nurse's priority is to withhold the medication and notify the healthcare provider about the potential allergic reaction.

Choice D:

This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.

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Question 30:

A client receiving an IV medication suddenly develops generalized hives, facial swelling, and difficulty breathing. The nurse should suspect which type of hypersensitivity reaction?

A. Type I (Immediate) hypersensitivity B. Type II (Cytotoxic) hypersensitivity C. Type III (Immune Complex-Mediated) hypersensitivity D. Type IV (Delayed) hypersensitivity

Answer and Explanation

Choice A:

This choice is correct. The client's sudden onset of hives, facial swelling, and difficulty breathing suggests a Type I (Immediate) hypersensitivity reaction, also known as anaphylaxis. Type I hypersensitivity reactions occur within minutes to hours after exposure to an allergen, leading to the release of histamine and other inflammatory mediators.

Choice B:

This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. They are not associated with the symptoms described by the client.

Choice C:

This choice is incorrect because Type III (Immune Complex-Mediated) hypersensitivity reactions involve the formation of immune complexes that deposit in tissues and trigger inflammation, but they do not typically present with generalized hives and facial swelling.

Choice D:

This choice is incorrect because Type IV (Delayed) hypersensitivity reactions occur 24 to 72 hours after exposure to an allergen and are mediated by T cells, leading to localized skin reactions like contact dermatitis. They are not associated with the rapid onset of symptoms described by the client.

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Question 31:

A nurse is caring for a client with a history of multiple drug allergies who requires IV therapy. Which intervention is essential to prevent an allergic reaction in this client?

A. Administering the IV medications rapidly to minimize exposure. B. Consulting with the healthcare provider to switch to oral medications. C. Using a smaller-gauge IV catheter for medication administration. D. Performing a thorough allergy assessment and using allergy alerts.

Answer and Explanation

Choice A:

This choice is incorrect because administering IV medications rapidly may increase the risk of an allergic reaction, especially in a client with a history of multiple drug allergies.

Choice B:

This choice is incorrect because switching to oral medications may not be appropriate or feasible for all IV medications. The nurse should consider alternative medications only after performing a thorough allergy assessment and consulting with the healthcare provider.

Choice C:

This choice is incorrect because the choice of IV catheter gauge is not directly related to preventing allergic reactions. It should be based on the medication's compatibility and viscosity.

Choice D:

This choice is correct. A thorough allergy assessment is essential in a client with a history of multiple drug allergies to identify potential allergens and prevent exposure to allergenic medications. The nurse should communicate allergies to the healthcare team and document them in the client's medical record, using allergy alerts or wristbands, to ensure safe medication administration.

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Question 32:

A client receiving an IV medication develops localized swelling, erythema, and pain at the IV site. The nurse assesses the client's vital signs and finds no signs of systemic allergic reaction. What is the nurse's priority action?

A. Discontinue the IV medication immediately. B. Administer an antihistamine to relieve the symptoms. C. Notify the healthcare provider about the localized reaction. D. Elevate the arm to reduce the swelling at the IV site.

Answer and Explanation

Choice A:

This choice is correct. The client's localized symptoms of swelling, erythema, and pain at the IV site may indicate a local allergic reaction or chemical irritation. The nurse should discontinue the IV medication immediately to prevent the progression of the reaction and assess the client further for any systemic signs of an allergic reaction.

Choice B:

This choice is not the priority action. While administering an antihistamine may relieve symptoms of an allergic reaction, the nurse's priority is to discontinue the IV medication and assess the client's condition.

Choice C:

This choice is not the priority action. While notifying the healthcare provider is important, the nurse's immediate priority is to discontinue the IV medication and assess the client's condition.

Choice D:

This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.

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Question 33:

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

A. Type I (Immediate) hypersensitivity B. Type II (Cytotoxic) hypersensitivity C. Type III (Immune Complex-Mediated) hypersensitivity D. Type IV (Delayed) hypersensitivity

Answer and Explanation

Choice A:

This choice is incorrect because Type I (Immediate) hypersensitivity reactions typically involve immediate symptoms like hives, facial swelling, and difficulty breathing, not fever, rash, and elevated liver enzymes.

Choice B:

This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. Elevated liver enzymes may occur in some drug-induced cytotoxic reactions, but they are not commonly associated with fever and rash.

Choice C:

This choice is correct. The client's symptoms of fever, rash, and elevated liver enzymes are potential signs of a Type III (Immune Complex-Mediated) hypersensitivity reaction. In this type of hypersensitivity, immune complexes formed by antibodies and antigens deposit in tissues and trigger inflammation, which can affect multiple organs, including the liver.

Choice D:

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Question 34:

A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

A. Use the same insertion site for all IV catheter changes. B. Change the IV catheter every 72 hours as per policy. C. Rotate the IV insertion site with each catheter change. D. Administer medications in large volumes to minimize insertion frequency.

Answer and Explanation

Choice A:

This choice is incorrect because using the same insertion site for all IV catheter changes can lead to complications such as phlebitis and infiltration due to repetitive trauma to the vein.

Choice B:

This choice is incorrect because changing the IV catheter every 72 hours as per policy may not be necessary unless the catheter is no longer functioning properly or the site shows signs of complications. Changing the catheter prematurely can increase the risk of complications.

Choice C:

This choice is correct. Rotating the IV insertion site with each catheter change helps to distribute the risk of complications across multiple sites and allows previously used sites time to heal and recover.

Choice D:

This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.

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Question 35:

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?

A. Phlebitis B. Air embolism C. Fluid overload D. Infiltration

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness and warmth, not shortness of breath, chest pain, and rapid heart rate.

Choice B:

This choice is correct. The client's symptoms of shortness of breath, chest pain, and rapid heart rate suggest an air embolism, which occurs when air enters the bloodstream through the IV catheter. This is a medical emergency, and the nurse should take immediate action to protect the client's airway, administer oxygen, and notify the healthcare provider.

Choice C:

This choice is incorrect because fluid overload is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate. It is characterized by symptoms such as edema and elevated blood pressure.

Choice D:

This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate.

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Question 36:

A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

A. Elevate the client's arm to reduce swelling. B. Apply a warm compress to the insertion site. C. Discontinue the IV infusion immediately. D. Administer an analgesic for pain relief.

Answer and Explanation

Choice A:

This choice is incorrect because elevating the client's arm may not address the underlying complication of infiltration. The nurse's priority is to discontinue the IV infusion to prevent further complications.

Choice B:

This choice is incorrect because applying a warm compress is not the priority action. The nurse should first discontinue the IV infusion to assess the site and determine appropriate interventions.

Choice C:

This choice is correct. The client's symptoms of pain, burning, redness, swelling, and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues. The nurse's priority is to discontinue the IV infusion to prevent further complications and assess the site for potential tissue damage.

Choice D:

This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

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Question 37:

A nurse is preparing to administer IV medications to a client. What should the nurse do to prevent medication incompatibilities during IV therapy?

A. Mix all the medications in one syringe for administration. B. Flush the IV line with a large amount of normal saline before administration. C. Consult with the pharmacist to verify medication compatibility. D. Increase the IV flow rate to hasten medication infusion.

Answer and Explanation

Choice A:

This choice is incorrect because mixing all the medications in one syringe is not recommended, as it may lead to medication incompatibilities or chemical reactions between medications.

Choice B:

This choice is incorrect because flushing the IV line with a large amount of normal saline does not prevent medication incompatibilities. It is essential to consult with the pharmacist to verify compatibility before administration.

Choice C:

This choice is correct. The nurse should consult with the pharmacist to verify the compatibility of the IV medications before administration. Certain medications may interact with each other or with the IV solution, leading to potential incompatibilities or adverse reactions.

Choice D:

This choice is incorrect because increasing the IV flow rate to hasten medication infusion does not prevent medication incompatibilities. It is essential to confirm compatibility before administering the medications.

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Question 38:

A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

A. Administering IV fluids through the largest available catheter. B. Changing the IV catheter dressing daily. C. Using sterile technique during IV insertion and care. D. Frequently accessing the IV catheter for blood draws.

Answer and Explanation

Choice A:

This choice is incorrect because administering IV fluids through the largest available catheter is not necessary for preventing CRBSIs. The appropriate catheter size should be based on the client's clinical needs and the prescribed therapy.

Choice B:

This choice is incorrect because changing the IV catheter dressing daily is not necessarily recommended unless the dressing is soiled or loose. Frequent dressing changes can increase the risk of contamination and infection. The nurse should follow evidence-based guidelines for catheter care and dressing changes.

Choice C:

This choice is correct. Using sterile technique during IV insertion and care is essential for preventing CRBSIs. Sterile technique helps to reduce the risk of introducing pathogens into the bloodstream, which can lead to infection.

Choice D:

This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.

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Question 39:

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect?

A. Phlebitis B. Infiltration C. Fluid overload D. Air embolism

Answer and Explanation

Choice A:

This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not coolness.

Choice B:

This choice is correct. The client's symptoms of swelling and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

Choice C:

This choice is incorrect because fluid overload is not associated with localized symptoms like swelling and coolness at the IV site.

Choice D:

This choice is incorrect because an air embolism is not associated with symptoms of swelling and coolness at the IV site.

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Complications of Intravenous therapy

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