A nurse is assessing a client who has an IV catheter in place for fluid administration. The nurse observes swelling, redness, and warmth around the insertion site. Which complication of IV therapy should the nurse suspect?

Phlebitis

Infiltration

Fluid overload

Air embolism

Answer and Explanation

The Correct Answer is A

A) This choice is correct. The client's symptoms of swelling, redness, and warmth around the insertion site are indicative of phlebitis, which is inflammation of the vein caused by irritants in the IV solution or mechanical trauma from the catheter.

B) This choice is incorrect because infiltration refers to the inadvertent administration of IV fluid into the surrounding tissues, causing swelling and coolness around the insertion site.

C) This choice is incorrect because fluid overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and bounding pulse, not local symptoms around the IV site.

D) This choice is incorrect because air embolism occurs when air enters the vascular system, leading to symptoms such as dyspnea, cyanosis, and chest pain, rather than localized symptoms at the insertion site.

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Correct Answer is D

Explanation

A) This choice is incorrect because phlebitis and infiltration typically do not cause chest pain, dyspnea, and tachycardia.

B) This choice is incorrect because infiltration is associated with localized symptoms around the IV site, not systemic symptoms like chest pain and dyspnea.

C) This choice is incorrect because fluid overload may cause respiratory distress and tachycardia, but it is not typically associated with sudden chest pain.

D) This choice is correct. The client's symptoms of sudden chest pain, dyspnea, and tachycardia are potential signs of an air embolism, which occurs when air enters the vascular system through the IV catheter and can lead to serious respiratory and cardiac complications.

A. Discontinue the IV medication immediately. B. Administer an antihistamine to relieve the symptoms. C. Notify the healthcare provider about the localized reaction. D. Elevate the arm to reduce the swelling at the IV site.

Correct Answer is A

Explanation

A) This choice is correct. The client's localized symptoms of swelling, erythema, and pain at the IV site may indicate a local allergic reaction or chemical irritation. The nurse should discontinue the IV medication immediately to prevent the progression of the reaction and assess the client further for any systemic signs of an allergic reaction.

B) This choice is not the priority action. While administering an antihistamine may relieve symptoms of an allergic reaction, the nurse's priority is to discontinue the IV medication and assess the client's condition.

C) This choice is not the priority action. While notifying the healthcare provider is important, the nurse's immediate priority is to discontinue the IV medication and assess the client's condition.

D) This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.

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A nurse is assessing a client who has an IV catheter in place for fluid administration. The nurse observes swelling, redness, and warmth around the insertion site. Which complication of IV therapy should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

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