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?

Infiltration

Phlebitis

Fluid overload

Sepsis

Answer and Explanation

The Correct Answer is D

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, confusion, and low blood pressure.

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, confusion, and low blood pressure.

C) This choice is incorrect because fluid overload is not associated with symptoms of fever, chills, and confusion. It may cause elevated blood pressure and edema.

D) This choice is correct. The client's symptoms of fever, chills, confusion, low blood pressure, and mottled skin 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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Correct Answer is C

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with purulent drainage and redness.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause purulent drainage.

C) This choice is correct. The client's symptoms of pain, redness, and purulent drainage at the IV site are indicative of an infection, which can occur as a complication of IV therapy, especially in clients with diabetes who may have compromised immune systems.

D) This choice is incorrect because thrombophlebitis does not typically cause purulent drainage at the insertion site.

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

Correct Answer is D

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues, not puncturing the vein. Burning pain is not typically associated with infiltration.

B) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not fluid leakage and burning pain.

C) This choice is incorrect because fluid overload is not related to the puncture of the vein and leakage of IV fluid. Symptoms of fluid overload include dyspnea, elevated blood pressure, and jugular vein distention.

D) This choice is correct. The nurse should suspect extravasation, which occurs when IV fluid or medication leaks into the surrounding tissues due to catheter puncture. Burning pain and discomfort at the insertion site are common symptoms of extravasation.

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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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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

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?

Correct Answer is D

Explanation

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?

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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?

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