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?
Infiltration
Phlebitis
Fluid overload
Sepsis
The Correct Answer is D
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, tachycardia, and hypotension.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, tachycardia, and hypotension.
C) This choice is incorrect because fluid overload is not associated with symptoms of fever, tachycardia, and hypotension. It is characterized by symptoms such as dyspnea and edema.
D) This choice is correct. The client's symptoms of fever, tachycardia, and hypotension are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
A) This choice is incorrect because applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.
B) This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.
C) This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.
D) This choice is incorrect because selecting a small-gauge catheter is not the primary intervention to prevent thrombophlebitis in a client with a history of DVT. The choice of catheter size should be based on the client's clinical needs and vein condition.
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