Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Discontinue the IV medication immediately.
This choice is correct. The client's localized symptoms of swelling, erythema, and pain at the IV site may indicate a local allergic reaction or chemical irritation. The nurse should discontinue the IV medication immediately to prevent the progression of the reaction and assess the client further for any systemic signs of an allergic reaction.
B. Administer an antihistamine to relieve the symptoms.
This choice is not the priority action. While administering an antihistamine may relieve symptoms of an allergic reaction, the nurse's priority is to discontinue the IV medication and assess the client's condition.
C. Notify the healthcare provider about the localized reaction.
This choice is not the priority action. While notifying the healthcare provider is important, the nurse's immediate priority is to discontinue the IV medication and assess the client's condition.
D. Elevate the arm to reduce the swelling at the IV site.
This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.
This question is an excerpt from Nurse Dive's nursing test bank - Complications of Intravenous therapy. Take the full exam now
Full Explanation
A) This choice is correct. The client's localized symptoms of swelling, erythema, and pain at the IV site may indicate a local allergic reaction or chemical irritation. The nurse should discontinue the IV medication immediately to prevent the progression of the reaction and assess the client further for any systemic signs of an allergic reaction.
B) This choice is not the priority action. While administering an antihistamine may relieve symptoms of an allergic reaction, the nurse's priority is to discontinue the IV medication and assess the client's condition.
C) This choice is not the priority action. While notifying the healthcare provider is important, the nurse's immediate priority is to discontinue the IV medication and assess the client's condition.
D) This choice is not the priority action. Elevating the arm may provide comfort, but the nurse's priority is to discontinue the IV medication and assess the client's condition for any signs of a systemic allergic reaction.
Similar Questions
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?
A. Type I (Immediate) hypersensitivity
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. Type II (Cytotoxic) hypersensitivity
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. Type III (Immune Complex-Mediated) hypersensitivity
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. Type IV (Delayed) hypersensitivity
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
Full 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 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. Use the same insertion site for all IV catheter changes.
This choice is incorrect because using the same insertion site for all IV catheter changes can lead to complications such as phlebitis and infiltration due to repetitive trauma to the vein.
B. Change the IV catheter every 72 hours as per policy.
This choice is incorrect because changing the IV catheter every 72 hours as per policy may not be necessary unless the catheter is no longer functioning properly or the site shows signs of complications. Changing the catheter prematurely can increase the risk of complications.
C. Rotate the IV insertion site with each catheter change.
This choice is correct. Rotating the IV insertion site with each catheter change helps to distribute the risk of complications across multiple sites and allows previously used sites time to heal and recover.
D. Administer medications in large volumes to minimize insertion frequency.
This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.
Full Explanation
A) This choice is incorrect because using the same insertion site for all IV catheter changes can lead to complications such as phlebitis and infiltration due to repetitive trauma to the vein.
B) This choice is incorrect because changing the IV catheter every 72 hours as per policy may not be necessary unless the catheter is no longer functioning properly or the site shows signs of complications. Changing the catheter prematurely can increase the risk of complications.
C) This choice is correct. Rotating the IV insertion site with each catheter change helps to distribute the risk of complications across multiple sites and allows previously used sites time to heal and recover.
D) This choice is incorrect because administering medications in large volumes to minimize insertion frequency is not a safe practice. Medication volumes should be appropriate for the client's needs, and insertion frequency should follow evidence-based guidelines.
A client receiving IV therapy suddenly develops shortness of breath, chest pain, and rapid heart rate. The nurse should suspect which complication and take immediate action?
A. Phlebitis
This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness and warmth, not shortness of breath, chest pain, and rapid heart rate.
B. Air embolism
This choice is correct. The client's symptoms of shortness of breath, chest pain, and rapid heart rate suggest an air embolism, which occurs when air enters the bloodstream through the IV catheter. This is a medical emergency, and the nurse should take immediate action to protect the client's airway, administer oxygen, and notify the healthcare provider.
C. Fluid overload
This choice is incorrect because fluid overload is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate. It is characterized by symptoms such as edema and elevated blood pressure.
D. Infiltration
This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate.
Full Explanation
A) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness and warmth, not shortness of breath, chest pain, and rapid heart rate.
B) This choice is correct. The client's symptoms of shortness of breath, chest pain, and rapid heart rate suggest an air embolism, which occurs when air enters the bloodstream through the IV catheter. This is a medical emergency, and the nurse should take immediate action to protect the client's airway, administer oxygen, and notify the healthcare provider.
C) This choice is incorrect because fluid overload is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate. It is characterized by symptoms such as edema and elevated blood pressure.
D) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with symptoms of shortness of breath, chest pain, and rapid heart rate.