A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

Type I (Immediate) hypersensitivity

Type II (Cytotoxic) hypersensitivity

Type III (Immune Complex-Mediated) hypersensitivity

Type IV (Delayed) hypersensitivity

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because Type I (Immediate) hypersensitivity reactions typically involve immediate symptoms like hives, facial swelling, and difficulty breathing, not fever, rash, and elevated liver enzymes.

B) This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. Elevated liver enzymes may occur in some drug-induced cytotoxic reactions, but they are not commonly associated with fever and rash.

C) This choice is correct. The client's symptoms of fever, rash, and elevated liver enzymes are potential signs of a Type III (Immune Complex-Mediated) hypersensitivity reaction. In this type of hypersensitivity, immune complexes formed by antibodies and antigens deposit in tissues and trigger inflammation, which can affect multiple organs, including the liver.

D) This choice is incorrect because Type IV (Delayed) hypersensitivity reactions occur 24 to 72 hours after exposure to an allergen and are mediated by T cells, leading to localized skin reactions like contact dermatitis. They are not associated with fever and elevated liver enzymes.

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Correct Answer is B

Explanation

A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site, not coolness.

B) This choice is correct. The client's symptoms of swelling and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

C) This choice is incorrect because fluid overload is not associated with localized symptoms like swelling and coolness at the IV site.

D) This choice is incorrect because an air embolism is not associated with symptoms of swelling and coolness at the IV site.

A. Administering IV fluids through the largest available catheter. B. Changing the IV catheter dressing daily. C. Using sterile technique during IV insertion and care. D. Frequently accessing the IV catheter for blood draws.

Correct Answer is C

Explanation

A) This choice is incorrect because administering IV fluids through the largest available catheter is not necessary for preventing CRBSIs. The appropriate catheter size should be based on the client's clinical needs and the prescribed therapy.

B) This choice is incorrect because changing the IV catheter dressing daily is not necessarily recommended unless the dressing is soiled or loose. Frequent dressing changes can increase the risk of contamination and infection. The nurse should follow evidence-based guidelines for catheter care and dressing changes.

C) This choice is correct. Using sterile technique during IV insertion and care is essential for preventing CRBSIs. Sterile technique helps to reduce the risk of introducing pathogens into the bloodstream, which can lead to infection.

D) This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.

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A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

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 notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect?

Correct Answer is B

Explanation

A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

Correct Answer is C

Explanation

A nurse is caring for a client with a peripheral IV catheter in place. The client complains of tenderness and a palpable, cord-like structure along the vein. The nurse should suspect which complication of IV therapy?

A nurse is caring for a client with a history of multiple drug allergies who requires IV therapy. Which intervention is essential to prevent an allergic reaction in this client?

A nurse is preparing to administer an IV medication to a client. Which action is essential to prevent complications during the medication administration?

A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?

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?

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?

A nurse is caring for a client receiving IV fluids and observes the client experiencing chills, fever, and elevated heart rate. The nurse should suspect which complication of IV therapy?

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?