A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client's vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?

Infiltration

Phlebitis

Fluid overload

Anaphylaxis

Answer and Explanation

The Correct Answer is D

A) This choice is incorrect because infiltration is not typically associated with symptoms of chest pain, difficulty breathing, decreased blood pressure, and weak pulse.

B) This choice is incorrect because phlebitis does not cause sudden onset chest pain, difficulty breathing, decreased blood pressure, and weak pulse.

C) This choice is incorrect because fluid overload is not associated with symptoms like chest pain and decreased blood pressure. It may cause elevated blood pressure due to increased fluid volume.

D) This choice is correct. The client's symptoms of sudden chest pain, difficulty breathing, decreased blood pressure, and weak pulse are indicative of anaphylaxis, a severe allergic reaction. Anaphylaxis can occur in response to an allergen in the IV fluid or medication and can be life-threatening if not treated promptly.

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Correct Answer is A

Explanation

A) This choice is correct. The client's localized symptoms of swelling, erythema, and pain at the IV site may indicate a local allergic reaction or chemical irritation. The nurse should discontinue the IV medication immediately to prevent the progression of the reaction and assess the client further for any systemic signs of an allergic reaction.

B) This choice is not the priority action. While administering an antihistamine may relieve symptoms of an allergic reaction, the nurse's priority is to discontinue the IV medication and assess the client's condition.

C) This choice is not the priority action. While notifying the healthcare provider is important, the nurse's immediate priority is to discontinue the IV medication and assess the client's condition.

D) This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.

A. Infiltration B. Phlebitis C. Sepsis D. Thrombophlebitis

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 fever, chills, and malaise.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, not red streaks along the vein path.

C) This choice is correct. The client's symptoms of fever, chills, malaise, and red streaks along the vein path are indicative of sepsis, which is a severe infection that can occur as a complication of IV therapy. Red streaks along the vein path may indicate the spread of infection along the vein.

D) This choice is incorrect because thrombophlebitis does not typically present with symptoms of fever, chills, and malaise. It is associated with tenderness and a palpable, cord-like structure along the vein.

Questions

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A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client's vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving an IV medication develops localized swelling, erythema, and pain at the IV site. The nurse assesses the client's vital signs and finds no signs of systemic allergic reaction. What is the nurse's priority action?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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