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 infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with warmth and swelling along the vein path.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause tenderness, warmth, and swelling along the vein path.

C) This choice is correct. The client's symptoms of tenderness, warmth, and swelling along the vein path are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can cause obstruction along the vein path, leading to the symptoms described by the client.

D) This choice is incorrect because sepsis typically presents with systemic symptoms like fever, chills, and confusion, not localized symptoms along the vein path.

Questions

A. Elevate the client's arm to reduce swelling. B. Apply a warm compress to the insertion site. C. Discontinue the IV infusion immediately. D. Administer an analgesic for pain relief.

Correct Answer is C

Explanation

A) This choice is incorrect because elevating the client's arm may not address the underlying complication of infiltration. The nurse's priority is to discontinue the IV infusion to prevent further complications.

B) This choice is incorrect because applying a warm compress is not the priority action. The nurse should first discontinue the IV infusion to assess the site and determine appropriate interventions.

C) This choice is correct. The client's symptoms of pain, burning, redness, swelling, and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues. The nurse's priority is to discontinue the IV infusion to prevent further complications and assess the site for potential tissue damage.

D) This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

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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 caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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?

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A client receiving IV medication complains of sudden chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of 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 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?

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