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?

Discontinue the IV medication immediately.

Administer an antihistamine to relieve the symptoms.

Notify the healthcare provider about the localized reaction.

Elevate the arm to reduce the swelling at the IV site.

Answer and Explanation

The Correct Answer is A

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.

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.

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.

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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Correct Answer is B

Explanation

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.

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.

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

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

Questions

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.

Correct Answer is A

Explanation

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.

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

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

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

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

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 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?