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?
Infiltration
Phlebitis
Fluid overload
Sepsis
The Correct Answer is D
A) This choice is incorrect because infiltration is not typically associated with chills, fever, and an elevated heart rate.
B) This choice is incorrect because phlebitis may cause local symptoms at the IV site but is not generally associated with systemic symptoms like fever and chills.
C) This choice is incorrect because fluid overload does not cause fever and chills but rather manifests as symptoms like dyspnea, edema, and increased blood pressure.
D) This choice is correct. The client's symptoms of chills, fever, and elevated heart rate are indicative of sepsis, a serious infection that can occur as a complication of IV therapy. Sepsis can develop if bacteria enter the bloodstream through the IV catheter and lead to a systemic inflammatory response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because infiltration is not typically associated with symptoms of chest pain, difficulty breathing, decreased blood pressure, and weak pulse.
B) This choice is incorrect because phlebitis does not cause sudden onset chest pain, difficulty breathing, decreased blood pressure, and weak pulse.
C) This choice is incorrect because fluid overload is not associated with symptoms like chest pain and decreased blood pressure. It may cause elevated blood pressure due to increased fluid volume.
D) This choice is correct. The client's symptoms of sudden chest pain, difficulty breathing, decreased blood pressure, and weak pulse are indicative of anaphylaxis, a severe allergic reaction. Anaphylaxis can occur in response to an allergen in the IV fluid or medication and can be life-threatening if not treated promptly.
Correct Answer is D
Explanation
A) This choice is incorrect because phlebitis typically presents with redness, warmth, and swelling around the insertion site but does not cause blistering of the skin.
B) This choice is incorrect because infiltration involves swelling and coolness around the IV site, not blistering and redness.
C) This choice is incorrect because fluid overload is not associated with pain, burning, swelling, or blistering around the IV site.
D) This choice is correct. The client's symptoms of pain, burning, swelling, redness, and blistering around the IV site are indicative of extravasation, which occurs when chemotherapy or other vesicant medications leak into the surrounding tissues, causing tissue damage and skin breakdown.
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