A patient was admitted for hypovolemia and has intravenous fluid ...

[tfester]

A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness.
 
  The nurse suspects that the a. IV has infiltrated.
  b. IV has caused phlebitis.
  c. Fluid is infusing too quickly.
  d. Patient is allergic to the fluid.

Question 2

The client receiving an intravenous infusion of morphine sulphate begins to experience respiratory depression and decreased urine output. How is this effect described?
 
  a. Therapeutic
  b. Toxic
  c. Idiosyncratic
  d. Allergic

[raenoj]

Answer to Question 1

C
The infusion may be flowing faster than the vein can handle, causing discomfort. The nurse should slow down the infusion. Infiltration results in skin that is blanched, cool, and edematous around the IV insertion site. Pain, warmth, erythema, and a palpable venous cord are all symptoms of phlebitis. Allergic response to the fluid could involve a combination of itching, flushing, hypotension, and dyspnea, depending on the severity.

Answer to Question 2

B
Toxic levels of morphine may cause severe respiratory depression. Toxic effects may develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. The client with a decreased urine output is not excreting the morphine.
The therapeutic effect is the expected or predictable physiological response a medication causes. Respiratory depression and decreased urine output are not the desired (i.e., therapeutic) effects of morphine.
An idiosyncratic effect occurs when a medication causes an unpredictable outcome, such as when a client overreacts or underreacts to a medication. This is not an example of an idiosyn-cratic effect.
When a client experiences an allergic response to a medication, the medication acts as an antigen, triggering the release of the body's antibodies. The client may experience itching, urticaria, a rash, or in more severe cases, may have difficulty breathing. This client's response to morphine is not an example of an allergic effect.