Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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 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.
Similar Questions
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.
A nurse is preparing to administer IV medications to a client. What should the nurse do to prevent medication incompatibilities during IV therapy?
A. Mix all the medications in one syringe for administration.
This choice is incorrect because mixing all the medications in one syringe is not recommended, as it may lead to medication incompatibilities or chemical reactions between medications.
B. Flush the IV line with a large amount of normal saline before administration.
This choice is incorrect because flushing the IV line with a large amount of normal saline does not prevent medication incompatibilities. It is essential to consult with the pharmacist to verify compatibility before administration.
C. Consult with the pharmacist to verify medication compatibility.
This choice is correct. The nurse should consult with the pharmacist to verify the compatibility of the IV medications before administration. Certain medications may interact with each other or with the IV solution, leading to potential incompatibilities or adverse reactions.
D. Increase the IV flow rate to hasten medication infusion.
This choice is incorrect because increasing the IV flow rate to hasten medication infusion does not prevent medication incompatibilities. It is essential to confirm compatibility before administering the medications.
Full Explanation
A) This choice is incorrect because mixing all the medications in one syringe is not recommended, as it may lead to medication incompatibilities or chemical reactions between medications.
B) This choice is incorrect because flushing the IV line with a large amount of normal saline does not prevent medication incompatibilities. It is essential to consult with the pharmacist to verify compatibility before administration.
C) This choice is correct. The nurse should consult with the pharmacist to verify the compatibility of the IV medications before administration. Certain medications may interact with each other or with the IV solution, leading to potential incompatibilities or adverse reactions.
D) This choice is incorrect because increasing the IV flow rate to hasten medication infusion does not prevent medication incompatibilities. It is essential to confirm compatibility before administering the medications.
A nurse is caring for a client receiving IV therapy. Which action is essential to prevent catheter-related bloodstream infections (CRBSIs)?
A. Administering IV fluids through the largest available catheter.
This choice is incorrect because administering IV fluids through the largest available catheter is not necessary for preventing CRBSIs. The appropriate catheter size should be based on the client's clinical needs and the prescribed therapy.
B. Changing the IV catheter dressing daily.
This choice is incorrect because changing the IV catheter dressing daily is not necessarily recommended unless the dressing is soiled or loose. Frequent dressing changes can increase the risk of contamination and infection. The nurse should follow evidence-based guidelines for catheter care and dressing changes.
C. Using sterile technique during IV insertion and care.
This choice is correct. Using sterile technique during IV insertion and care is essential for preventing CRBSIs. Sterile technique helps to reduce the risk of introducing pathogens into the bloodstream, which can lead to infection.
D. Frequently accessing the IV catheter for blood draws.
This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.
Full Explanation
A) This choice is incorrect because administering IV fluids through the largest available catheter is not necessary for preventing CRBSIs. The appropriate catheter size should be based on the client's clinical needs and the prescribed therapy.
B) This choice is incorrect because changing the IV catheter dressing daily is not necessarily recommended unless the dressing is soiled or loose. Frequent dressing changes can increase the risk of contamination and infection. The nurse should follow evidence-based guidelines for catheter care and dressing changes.
C) This choice is correct. Using sterile technique during IV insertion and care is essential for preventing CRBSIs. Sterile technique helps to reduce the risk of introducing pathogens into the bloodstream, which can lead to infection.
D) This choice is incorrect because frequently accessing the IV catheter for blood draws can increase the risk of CRBSIs. The nurse should minimize unnecessary catheter access and follow aseptic technique when drawing blood or administering medications through the catheter.