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 D

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not puncturing the vein. Burning pain is not typically associated with infiltration.

B) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not fluid leakage and burning pain.

C) This choice is incorrect because fluid overload is not related to the puncture of the vein and leakage of IV fluid. Symptoms of fluid overload include dyspnea, elevated blood pressure, and jugular vein distention.

D) This choice is correct. The nurse should suspect extravasation, which occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture. Burning pain and discomfort at the insertion site are common symptoms of extravasation.

A. Stop the IV infusion immediately. B. Elevate the arm to promote venous return. C. Apply a warm compress to the site for comfort. D. Administer a prescribed analgesic.

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.

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 nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

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?

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