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 B
Explanation
A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not coolness and pallor.
B) This choice is correct. The client's symptoms of swelling, coolness, and pallor around the insertion site, along with a slowed infusion and discomfort, are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.
C) This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.
D) This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as swelling and coolness around the IV site.
Correct Answer is A
Explanation
A) This choice is correct. The client's symptoms of pain, burning, redness, and tenderness at the insertion site are indicative of a potential complication, such as phlebitis or infiltration. The nurse should stop the IV infusion immediately to prevent further damage.
B) This choice is incorrect because elevating the arm may not address the underlying complication of phlebitis or infiltration.
C) This choice is incorrect because applying a warm compress is not the priority. The nurse should first stop the infusion to prevent complications.
D) This choice is incorrect because administering an analgesic may provide temporary relief, but it does not address the potential complication causing the client's symptoms. The nurse should first stop the IV infusion to assess the site and determine appropriate interventions.
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