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, 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. Infiltration B. Phlebitis C. Fluid overload D. Air embolism

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

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