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 A

Explanation

A) This choice is correct. The client's sudden onset of hives, facial swelling, and difficulty breathing suggests a Type I (Immediate) hypersensitivity reaction, also known as anaphylaxis. Type I hypersensitivity reactions occur within minutes to hours after exposure to an allergen, leading to the release of histamine and other inflammatory mediators.

B) This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. They are not associated with the symptoms described by the client.

C) This choice is incorrect because Type III (Immune Complex-Mediated) hypersensitivity reactions involve the formation of immune complexes that deposit in tissues and trigger inflammation, but they do not typically present with generalized hives and facial swelling.

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 the rapid onset of symptoms described by the client.

A. Administering the medication rapidly to ensure a quick effect. B. Diluting the medication with a large volume of IV fluid. C. Checking the client's allergies and medication compatibility. D. Using a smaller gauge IV catheter for the medication infusion.

Correct Answer is C

Explanation

A) This choice is incorrect because administering the medication rapidly is not necessarily essential and can increase the risk of complications. Medications should be administered at the appropriate rate to prevent adverse effects.

B) This choice is incorrect because diluting the medication with a large volume of IV fluid may be unnecessary and may slow down the administration without specific indications.

C) This choice is correct. Checking the client's allergies and medication compatibility is essential to prevent adverse reactions and complications. Ensuring that the prescribed medication is appropriate for the client and does not interact negatively with other medications or allergies is crucial.

D) This choice is incorrect because the choice of IV catheter size depends on the medication's compatibility and viscosity, not just using a smaller gauge catheter for all medication infusions.

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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 an IV medication suddenly develops generalized hives, facial swelling, and difficulty breathing. The nurse should suspect which type of hypersensitivity reaction?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

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

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

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 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?