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 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.

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.

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.

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.

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

Correct Answer is C

Explanation

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

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.

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.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

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

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

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 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?