Which assessment finding indicates a possible adverse IV medication reaction?
Rash, itching or shortness of breath
Client reports coolness at IV site.
Blood return in the catheter
Mild discomfort at insertion
The Correct Answer is A
Rationale:
A. Rash, itching, or shortness of breath is correct because these are hallmark signs of an allergic or adverse reaction to IV medications. Symptoms may range from mild reactions like localized rash and pruritus to severe reactions such as anaphylaxis, which can include bronchospasm, hypotension, and respiratory distress. Immediate action is required, including stopping the infusion, notifying the provider, and administering emergency interventions if needed.
B. Client reports coolness at IV site is incorrect because coolness indicates infiltration, where IV fluid leaks into the surrounding tissue. Other signs of infiltration include pallor, swelling, and discomfort at the site. This is a local complication of IV therapy, not a systemic adverse medication reaction. It requires removal of the catheter and monitoring of the site, but it does not indicate an allergic reaction.
C. Blood return in the catheter is incorrect because blood return (also called flashback) indicates that the catheter is correctly placed in the vein. This is a normal finding, not a complication or reaction. It demonstrates patency and proper placement for infusion, and therefore does not signify an adverse effect of the medication.
D. Mild discomfort at insertion is incorrect because minor pain or discomfort during IV insertion is expected due to needle penetration of the skin and vein. This is normal procedural discomfort, not an adverse reaction. Nurses should still monitor for signs of phlebitis, infiltration, or infection, but mild insertion pain alone does not indicate a systemic medication reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Non-dominant forearm is incorrect because the non-dominant arm is preferred for IV insertion to minimize interference with the patient’s daily activities and reduce the risk of accidental dislodgement.
B. Areas of flexion is correct because IVs placed over joints such as the wrist, antecubital fossa, or elbow are prone to mechanical complications. Movement at the joint can cause dislodgement, infiltration, phlebitis, or occlusion of the catheter, making these areas less ideal for routine IV placement.
C. Upper extremity veins is incorrect because veins in the upper extremity are the preferred sites for peripheral IV access due to ease of access, visibility, and patient comfort.
D. A stable, palpable vein is incorrect because a palpable vein that does not roll and is stable is ideal for IV insertion. Such veins are less likely to infiltrate or dislodge and provide reliable access for infusion.
Correct Answer is C
Explanation
Rationale:
A. Use the largest vein possible is incorrect because vein selection should prioritize patient safety and comfort, not simply size. A smaller, accessible, and stable vein may be preferable, and using a large vein unnecessarily may increase risk of mechanical complications or infiltration.
B. Administer as rapidly as tolerated is incorrect because rapid administration of IV medications can cause adverse reactions, cardiovascular instability, or local irritation. IV medications should always be administered at the recommended rate specified in the provider’s order or medication guidelines.
C. Confirm medication compatibility with IV fluids is correct. The LVN must always check for chemical compatibility between the IV medication and any fluids running through the line. Incompatible medications can precipitate, reduce efficacy, or cause dangerous reactions, which may lead to emboli, phlebitis, or other complications. This step ensures safe and effective IV therapy.
D. Avoid flushing between medications is incorrect because flushing between medications is essential to prevent chemical incompatibilities and ensure that each medication reaches the bloodstream fully and safely. Skipping this step increases the risk of precipitation and adverse reactions.
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