A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

The client prefers IV therapy over oral fluids.

The client has a history of IV drug use.

The client is unable to tolerate oral intake.

The client's family requested IV therapy.

Answer and Explanation

The Correct Answer is C

A) This choice is incorrect because the client's preference for IV therapy over oral fluids is not a valid indication for initiating IV therapy. Clinical indications should guide the decision, not personal preferences.

B) This choice is incorrect because a history of IV drug use does not automatically indicate a need for IV therapy for dehydration. The client's current condition and clinical status should determine the need for IV fluids.

C) This choice is correct. In cases of severe dehydration where the client is unable to tolerate oral intake, IV therapy is essential to provide rapid rehydration and restore fluid and electrolyte balance.

D) This choice is incorrect because the family's request alone is not a sufficient indication for initiating IV therapy. The decision should be based on the client's clinical condition and medical needs.

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Correct Answer is C

Explanation

A) This choice is incorrect because Type I (Immediate) hypersensitivity reactions typically involve immediate symptoms like hives, facial swelling, and difficulty breathing, not fever, rash, and elevated liver enzymes.

B) This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. Elevated liver enzymes may occur in some drug-induced cytotoxic reactions, but they are not commonly associated with fever and rash.

C) This choice is correct. The client's symptoms of fever, rash, and elevated liver enzymes are potential signs of a Type III (Immune Complex-Mediated) hypersensitivity reaction. In this type of hypersensitivity, immune complexes formed by antibodies and antigens deposit in tissues and trigger inflammation, which can affect multiple organs, including the liver.

D) This choice is incorrect because Type IV (Delayed) hypersensitivity reactions occur 24 to 72 hours after exposure to an allergen and are mediated by T cells, leading to localized skin reactions like contact dermatitis. They are not associated with fever and elevated liver enzymes.

Questions

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

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.

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A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

Correct Answer is C

Explanation

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 nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?

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

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?

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes swelling, coolness, and pallor around the insertion site. The infusion has slowed, and the client reports discomfort. Which complication of IV therapy should the nurse suspect?

A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?

A client receiving IV fluids complains of a cool sensation around the insertion site, and the nurse observes swelling and blanching of the skin. Which complication of IV therapy should the nurse suspect?

A client with a history of diabetes is receiving IV therapy. The client complains of pain and redness at the IV site, and the nurse notices purulent drainage. 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?