Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Infiltration
This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, confusion, and low blood pressure.
B. Phlebitis
This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, confusion, and low blood pressure.
C. Fluid overload
This choice is incorrect because fluid overload is not associated with symptoms of fever, chills, and confusion. It may cause elevated blood pressure and edema.
D. Sepsis
This choice is correct. The client's symptoms of fever, chills, confusion, low blood pressure, and mottled skin are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.
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 infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, confusion, and low blood pressure.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, confusion, and low blood pressure.
C) This choice is incorrect because fluid overload is not associated with symptoms of fever, chills, and confusion. It may cause elevated blood pressure and edema.
D) This choice is correct. The client's symptoms of fever, chills, confusion, low blood pressure, and mottled skin are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.
Similar Questions
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?
A. Infiltration
This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with warmth and swelling along the vein path.
B. Phlebitis
This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause tenderness, warmth, and swelling along the vein path.
C. Thrombophlebitis
This choice is correct. The client's symptoms of tenderness, warmth, and swelling along the vein path are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can cause obstruction along the vein path, leading to the symptoms described by the client.
D. Sepsis
This choice is incorrect because sepsis typically presents with systemic symptoms like fever, chills, and confusion, not localized symptoms along the vein path.Questions
Full Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with warmth and swelling along the vein path.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site, such as redness, warmth, and swelling, but it does not cause tenderness, warmth, and swelling along the vein path.
C) This choice is correct. The client's symptoms of tenderness, warmth, and swelling along the vein path are indicative of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can cause obstruction along the vein path, leading to the symptoms described by the client.
D) This choice is incorrect because sepsis typically presents with systemic symptoms like fever, chills, and confusion, not localized symptoms along the vein path.
Questions
A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?
A. Administer the medication as prescribed.
This choice is incorrect because administering the medication as prescribed may exacerbate the allergic reaction and is not safe without further assessment and medical guidance.
B. Withhold the medication and notify the healthcare provider.
This choice is correct. The client's statement about being allergic to penicillin and experiencing itchiness in the throat suggests a potential allergic reaction. The nurse should withhold the medication and promptly notify the healthcare provider to assess the client's allergic response and determine an alternative course of action.
C. Ask the client to rate the severity of the itchiness.
This choice is not the priority action. While assessing the severity of the itchiness is important, the nurse's priority is to withhold the medication and notify the healthcare provider about the potential allergic reaction.
D. Administer an antihistamine before giving the medication.
This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.
Full Explanation
A) This choice is incorrect because administering the medication as prescribed may exacerbate the allergic reaction and is not safe without further assessment and medical guidance.
B) This choice is correct. The client's statement about being allergic to penicillin and experiencing itchiness in the throat suggests a potential allergic reaction. The nurse should withhold the medication and promptly notify the healthcare provider to assess the client's allergic response and determine an alternative course of action.
C) This choice is not the priority action. While assessing the severity of the itchiness is important, the nurse's priority is to withhold the medication and notify the healthcare provider about the potential allergic reaction.
D) This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.
A client receiving an IV medication suddenly develops generalized hives, facial swelling, and difficulty breathing. The nurse should suspect which type of hypersensitivity reaction?
A. Type I (Immediate) hypersensitivity
This choice is correct. The client's sudden onset of hives, facial swelling, and difficulty breathing suggests a Type I (Immediate) hypersensitivity reaction, also known as anaphylaxis. Type I hypersensitivity reactions occur within minutes to hours after exposure to an allergen, leading to the release of histamine and other inflammatory mediators.
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. They are not associated with the symptoms described by the client.
C. Type III (Immune Complex-Mediated) hypersensitivity
This choice is incorrect because Type III (Immune Complex-Mediated) hypersensitivity reactions involve the formation of immune complexes that deposit in tissues and trigger inflammation, but they do not typically present with generalized hives and facial swelling.
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 the rapid onset of symptoms described by the client.
Full Explanation
A) This choice is correct. The client's sudden onset of hives, facial swelling, and difficulty breathing suggests a Type I (Immediate) hypersensitivity reaction, also known as anaphylaxis. Type I hypersensitivity reactions occur within minutes to hours after exposure to an allergen, leading to the release of histamine and other inflammatory mediators.
B) This choice is incorrect because Type II (Cytotoxic) hypersensitivity reactions involve antibodies attacking specific cells or tissues, leading to cell destruction. They are not associated with the symptoms described by the client.
C) This choice is incorrect because Type III (Immune Complex-Mediated) hypersensitivity reactions involve the formation of immune complexes that deposit in tissues and trigger inflammation, but they do not typically present with generalized hives and facial swelling.
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 the rapid onset of symptoms described by the client.