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 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. Type I (Immediate) hypersensitivity B. Type II (Cytotoxic) hypersensitivity C. Type III (Immune Complex-Mediated) hypersensitivity D. Type IV (Delayed) hypersensitivity

Correct Answer is C

Explanation

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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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 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 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?

Correct Answer is C

Explanation

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?

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 fluids develops a fever, tachycardia, and hypotension. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

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?

A client receiving an IV medication develops localized swelling, erythema, and pain at the IV site. The nurse assesses the client's vital signs and finds no signs of systemic allergic reaction. What is the nurse's priority action?

A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. The nurse should suspect which complication of IV therapy?

A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

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?