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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) This choice is incorrect because administering IV medications rapidly may increase the risk of an allergic reaction, especially in a client with a history of multiple drug allergies.

B) This choice is incorrect because switching to oral medications may not be appropriate or feasible for all IV medications. The nurse should consider alternative medications only after performing a thorough allergy assessment and consulting with the healthcare provider.

C) This choice is incorrect because the choice of IV catheter gauge is not directly related to preventing allergic reactions. It should be based on the medication's compatibility and viscosity.

D) This choice is correct. A thorough allergy assessment is essential in a client with a history of multiple drug allergies to identify potential allergens and prevent exposure to allergenic medications. The nurse should communicate allergies to the healthcare team and document them in the client's medical record, using allergy alerts or wristbands, to ensure safe medication administration.

A. Type I (Immediate) hypersensitivity B. Type II (Cytotoxic) hypersensitivity C. Type III (Immune Complex-Mediated) hypersensitivity D. Type IV (Delayed) hypersensitivity

Correct Answer is C

Explanation

A) This choice is incorrect because Type I (Immediate) hypersensitivity reactions typically involve immediate symptoms like hives, facial swelling, and difficulty breathing, not fever, rash, and elevated liver enzymes.

B) This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. Elevated liver enzymes may occur in some drug-induced cytotoxic reactions, but they are not commonly associated with fever and rash.

C) This choice is correct. The client's symptoms of fever, rash, and elevated liver enzymes are potential signs of a Type III (Immune Complex-Mediated) hypersensitivity reaction. In this type of hypersensitivity, immune complexes formed by antibodies and antigens deposit in tissues and trigger inflammation, which can affect multiple organs, including the liver.

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 fever and elevated liver enzymes.

Questions

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a history of multiple drug allergies who requires IV therapy. Which intervention is essential to prevent an allergic reaction in this client?

Correct Answer is D

Explanation

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

Correct Answer is C

Explanation

A nurse is assessing a client receiving IV fluids and notes the presence of fever, chills, and confusion. The client's blood pressure is low, and the skin appears mottled. The nurse should recognize these symptoms as potential signs of which complication?

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

A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. The nurse should suspect which complication of IV therapy?

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 nurse is preparing to administer IV medications to a client. What should the nurse do to prevent medication incompatibilities during IV therapy?

A nurse is preparing to administer an IV medication to a client. Which action is essential to prevent complications during the medication administration?

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect?

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?