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?

Stop the IV infusion immediately.

Elevate the arm to promote venous return.

Apply a warm compress to the site for comfort.

Administer a prescribed analgesic.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is D

Explanation

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.

A. Phlebitis B. Infiltration C. Fluid overload D. Catheter occlusion

Correct Answer is C

Explanation

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

A nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?

A client with a history of heart failure is receiving IV fluids. The nurse should closely monitor the client for which potential complication?

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?

A client receiving IV medications develops a painful, warm, and red streak along the arm near the IV site. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

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?

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication?

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?