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?

Phlebitis

Infiltration

Fluid overload

Extravasation

Answer and Explanation

The Correct Answer is D

A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.

B) This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.

C) This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.

D) This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.

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Correct Answer is B

Explanation

A) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness and warmth, not shortness of breath, chest pain, and rapid heart rate.

B) This choice is correct. The client's symptoms of shortness of breath, chest pain, and rapid heart rate suggest an air embolism, which occurs when air enters the bloodstream through the IV catheter. This is a medical emergency, and the nurse should take immediate action to protect the client's airway, administer oxygen, and notify the healthcare provider.

C) This choice is incorrect because fluid overload is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate. It is characterized by symptoms such as edema and elevated blood pressure.

D) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate.

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

Correct Answer is D

Explanation

A) This choice is incorrect because infiltration is not typically associated with chills, fever, and an elevated heart rate.

B) This choice is incorrect because phlebitis may cause local symptoms at the IV site but is not generally associated with systemic symptoms like fever and chills.

C) This choice is incorrect because fluid overload does not cause fever and chills but rather manifests as symptoms like dyspnea, edema, and increased blood pressure.

D) This choice is correct. The client's symptoms of chills, fever, and elevated heart rate are indicative of sepsis, a serious infection that can occur as a complication of IV therapy. Sepsis can develop if bacteria enter the bloodstream through the IV catheter and lead to a systemic inflammatory response.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

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