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 C

Explanation

A) This choice is incorrect because using the same insertion site for all IV catheter changes can lead to complications such as phlebitis and infiltration due to repetitive trauma to the vein.

B) This choice is incorrect because changing the IV catheter every 72 hours as per policy may not be necessary unless the catheter is no longer functioning properly or the site shows signs of complications. Changing the catheter prematurely can increase the risk of complications.

C) This choice is correct. Rotating the IV insertion site with each catheter change helps to distribute the risk of complications across multiple sites and allows previously used sites time to heal and recover.

D) This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.

A. Infiltration B. Phlebitis C. Fluid overload D. Sepsis

Correct Answer is D

Explanation

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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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 nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

Correct Answer is C

Explanation

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?

Correct Answer is D

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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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?

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A client receiving IV fluids complains of a cool sensation around the insertion site, and the nurse observes swelling and blanching of the skin. Which complication of IV therapy should the nurse suspect?

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