A client receiving IV fluids suddenly experiences shortness of breath, crackles in the lungs, and jugular vein distention. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

Phlebitis

Infiltration

Fluid overload

Catheter occlusion

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because phlebitis and infiltration are not associated with symptoms of shortness of breath, crackles in the lungs, and jugular vein distention.

B) This choice is incorrect because infiltration typically does not cause respiratory symptoms like shortness of breath and crackles in the lungs.

C) This choice is correct. The client's symptoms of shortness of breath, crackles in the lungs (rales), and jugular vein distention are potential signs of fluid overload, which occurs when there is an excessive volume of IV fluids administered.

D) This choice is incorrect because catheter occlusion does not cause respiratory symptoms like those described by the client.

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Correct Answer is C

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not redness, warmth, and tenderness around the insertion site.

B) This choice is incorrect because extravasation occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture, but it does not present with redness and swelling.

C) This choice is correct. The client's symptoms of redness, warmth, swelling, tenderness, and pain around the insertion site are indicative of phlebitis, which is the inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.

D) This choice is incorrect because an air embolism is not associated with symptoms of phlebitis, such as redness and swelling around the IV site.

A. Applying a warm compress to the IV site. B. Limiting the use of the affected arm for IV insertion. C. Avoiding the use of a tourniquet during IV insertion. D. Selecting a small-gauge catheter for the IV insertion.

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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A client receiving IV fluids suddenly experiences shortness of breath, crackles in the lungs, and jugular vein distention. 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 an IV catheter in place for medication administration. The nurse observes redness, warmth, and swelling around the insertion site, and the client reports tenderness and pain. Which complication of IV therapy should the nurse suspect?

Correct Answer is C

Explanation

A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

Correct Answer is C

Explanation

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A nurse is assessing a client who has an IV catheter in place for fluid administration. The nurse observes swelling, redness, and warmth around the insertion site. Which complication of IV therapy should the nurse suspect?