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?

Elevate the client's arm to reduce swelling.

Apply a warm compress to the insertion site.

Discontinue the IV infusion immediately.

Administer an analgesic for pain relief.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because elevating the client's arm may not address the underlying complication of infiltration. The nurse's priority is to discontinue the IV infusion to prevent further complications.

B) This choice is incorrect because applying a warm compress is not the priority action. The nurse should first discontinue the IV infusion to assess the site and determine appropriate interventions.

C) This choice is correct. The client's symptoms of pain, burning, redness, swelling, and coolness around the insertion site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues. The nurse's priority is to discontinue the IV infusion to prevent further complications and assess the site for potential tissue damage.

D) This choice is incorrect because administering an analgesic may provide temporary pain relief, but it does not address the underlying complication of infiltration. The nurse should first discontinue the IV infusion and assess the site for potential complications.

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Correct Answer is C

Explanation

A) This choice is incorrect because phlebitis and infiltration are not associated with symptoms of shortness of breath, crackles in the lungs, and jugular vein distention.

B) This choice is incorrect because infiltration typically does not cause respiratory symptoms like shortness of breath and crackles in the lungs.

C) This choice is correct. The client's symptoms of shortness of breath, crackles in the lungs (rales), and jugular vein distention are potential signs of fluid overload, which occurs when there is an excessive volume of IV fluids administered.

D) This choice is incorrect because catheter occlusion does not cause respiratory symptoms like those described by the client.

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

Correct Answer is D

Explanation

A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with chest pain, dyspnea, and tachycardia.

B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with chest pain, dyspnea, and tachycardia.

C) This choice is incorrect because fluid overload does not typically cause chest pain, dyspnea, and tachycardia but rather manifests as symptoms such as elevated blood pressure, jugular vein distention, and edema.

D) This choice is correct. The client's symptoms of chest pain, dyspnea, and tachycardia are potential signs of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can become dislodged and travel to the lungs, leading to a pulmonary embolism, which presents with chest pain and dyspnea.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving IV fluids suddenly experiences shortness of breath, crackles in the lungs, and jugular vein distention. The nurse should recognize these symptoms as potential signs of which complication of IV therapy?

Correct Answer is C

Explanation

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication?

Correct Answer is D

Explanation

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?

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

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?

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?

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

A nurse is caring for a client with a history of multiple drug allergies who requires IV therapy. Which intervention is essential to prevent an allergic reaction in this client?

A client receiving IV therapy develops a fever, chills, and malaise. The nurse notices red streaks along the vein path. Which complication of IV therapy should the nurse suspect?