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

Infiltration

Phlebitis

Fluid overload

Air embolism

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because infiltration is not directly related to the client's history of heart failure.

B) This choice is incorrect because phlebitis is not specifically associated with heart failure but rather with irritants in the IV solution or mechanical trauma.

C) This choice is correct. Clients with a history of heart failure are at an increased risk of fluid overload due to their compromised cardiac function. Monitoring for signs of fluid overload, such as dyspnea, jugular vein distention, and peripheral edema, is essential during IV therapy.

D) This choice is incorrect because an air embolism is not directly related to the client's history of heart failure.

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Correct Answer is B

Explanation

A) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not blanching of the skin.

B) This choice is correct. The client's symptoms of a cool sensation, swelling, and blanching of the skin 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 local symptoms around the insertion site.

D) This choice is incorrect because catheter occlusion may affect the IV flow rate, but it does not typically cause the symptoms described by the client.

A. Administer the medication as prescribed. B. Withhold the medication and notify the healthcare provider. C. Ask the client to rate the severity of the itchiness. D. Administer an antihistamine before giving the medication.

Correct Answer is B

Explanation

A) This choice is incorrect because administering the medication as prescribed may exacerbate the allergic reaction and is not safe without further assessment and medical guidance.

B) This choice is correct. The client's statement about being allergic to penicillin and experiencing itchiness in the throat suggests a potential allergic reaction. The nurse should withhold the medication and promptly notify the healthcare provider to assess the client's allergic response and determine an alternative course of action.

C) This choice is not the priority action. While assessing the severity of the itchiness is important, the nurse's priority is to withhold the medication and notify the healthcare provider about the potential allergic reaction.

D) This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

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?

A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

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?

A nurse is preparing to administer IV medications to a client. What should the nurse do to prevent medication incompatibilities during IV therapy?

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

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?

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