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 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

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

Correct Answer is B

Explanation

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

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.

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

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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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 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 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?

Correct Answer is B

Explanation

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

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