A nurse is caring for a client with an IV catheter in place for fluid administration. The nurse observes the client's arm is edematous, and the skin feels cool to the touch. The infusion is sluggish, and the client reports discomfort at the site. Which complication of IV therapy should the nurse suspect?

Phlebitis

Infiltration

Fluid overload

Air embolism

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because phlebitis is characterized by redness, warmth, and swelling around the insertion site, not edema and coolness.

B) This choice is correct. The client's symptoms of edema, coolness, sluggish infusion, and discomfort at the site are indicative of infiltration, which occurs when IV fluid leaks into the surrounding tissues.

C) This choice is incorrect because fluid overload is not associated with localized symptoms like those described by the client.

D) This choice is incorrect because an air embolism is not associated with symptoms of infiltration, such as edema and coolness around the IV site.

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Correct Answer is C

Explanation

A) This choice is incorrect because applying a warm compress is not necessarily essential to prevent thrombophlebitis. It may provide comfort but does not directly prevent its development.

B) This choice is incorrect because limiting the use of the affected arm for IV insertion may not be necessary. The choice of insertion site should be based on the client's clinical condition and the nurse's assessment.

C) This choice is correct. The nurse should avoid using a tourniquet during IV insertion in a client with a history of DVT to minimize trauma to the vein and reduce the risk of thrombophlebitis formation.

D) This choice is incorrect because selecting a small-gauge catheter is not the primary intervention to prevent thrombophlebitis in a client with a history of DVT. The choice of catheter size should be based on the client's clinical needs and vein condition.

A. Administering the IV medications rapidly to minimize exposure. B. Consulting with the healthcare provider to switch to oral medications. C. Using a smaller-gauge IV catheter for medication administration. D. Performing a thorough allergy assessment and using allergy alerts.

Correct Answer is D

Explanation

A) This choice is incorrect because administering IV medications rapidly may increase the risk of an allergic reaction, especially in a client with a history of multiple drug allergies.

B) This choice is incorrect because switching to oral medications may not be appropriate or feasible for all IV medications. The nurse should consider alternative medications only after performing a thorough allergy assessment and consulting with the healthcare provider.

C) This choice is incorrect because the choice of IV catheter gauge is not directly related to preventing allergic reactions. It should be based on the medication's compatibility and viscosity.

D) This choice is correct. A thorough allergy assessment is essential in a client with a history of multiple drug allergies to identify potential allergens and prevent exposure to allergenic medications. The nurse should communicate allergies to the healthcare team and document them in the client's medical record, using allergy alerts or wristbands, to ensure safe medication administration.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a history of deep vein thrombosis (DVT) who requires IV therapy. Which intervention is essential to prevent the development of thrombophlebitis in this client?

Correct Answer is C

Explanation

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?

Correct Answer is D

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?

A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?

A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client's vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?

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?

A nurse is caring for a client with a peripheral IV catheter in place. The client complains of tenderness and a palpable, cord-like structure along the vein. The nurse should suspect which complication of IV therapy?

A nurse is caring for a client with a peripheral IV catheter in place. The client reports tenderness, warmth, and swelling along the vein path. The nurse should suspect which complication of IV therapy?

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse notes swelling and coolness around the insertion site. Which complication of IV therapy should the nurse suspect?

A client receiving chemotherapy through an IV complains of pain, burning, and swelling around the IV site. The nurse notices the skin turning red and blistering. Which complication of IV therapy should the nurse suspect?