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 A

Explanation

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.

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.

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.

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.

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.

Correct Answer is D

Explanation

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.

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.

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.

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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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 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?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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

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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 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 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 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?