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

Type I (Immediate) hypersensitivity

Type II (Cytotoxic) hypersensitivity

Type III (Immune Complex-Mediated) hypersensitivity

Type IV (Delayed) hypersensitivity

Answer and Explanation

The Correct Answer is A

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.

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.

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.

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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Correct Answer is C

Explanation

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.

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.

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.

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.

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

Correct Answer is C

Explanation

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.

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.

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.

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

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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

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

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 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 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 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?