Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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
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 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
Similar 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.
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. Elevate the client's arm to reduce swelling.
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. Apply a warm compress to the insertion site.
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. Discontinue the IV infusion immediately.
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. Administer an analgesic for pain relief.
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.
Full Explanation
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.