A nurse is administering fluids to a client.
Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

Auscultate lung sounds

Measure urine output

Monitor blood pressure readings

Monitor electrolyte levels . .

Answer and Explanation

The Correct Answer is A

Choice A rationale

Auscultating lung sounds is the priority when monitoring for adverse effects of administering IV fluids. Fluid overload can lead to pulmonary edema, which would be detected by abnormal lung sounds such as crackles.

Choice B rationale

While measuring urine output is important to assess kidney function and fluid balance, it is not the priority in this case.

Choice C rationale

Monitoring blood pressure readings is important when administering IV fluids, but it is not the priority in this case.

Choice D rationale

Monitoring electrolyte levels is important when administering IV fluids, but it is not the priority in this case.

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Correct Answer is D

Explanation

Choice A rationale

Discussing the risk factors for colon cancer may not be helpful or comforting to a client who is expressing anger about their diagnosis. It might lead to feelings of guilt or regret if the client feels they could have done something to prevent the disease.

Choice B rationale

Focusing on future management of the illness may be overwhelming for a client who is currently expressing anger about their diagnosis. It might be more beneficial to address the client’s current emotional state before discussing future plans.

Choice C rationale

Providing written information about the phases of loss and grief may be helpful, but it may not address the client’s immediate emotional needs. The client may not be ready to read and process this information while they are expressing anger.

Choice D rationale

Reassuring the client that anger is an expected response to grief can validate the client’s feelings and help them feel understood. It’s important to acknowledge and validate the client’s emotions during this difficult time.

A. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client’s wishes. B. A client who has a do-not-resuscitate (DNR) order experiences a cardiac arrest, and the nurse does not perform CPR despite requests from the client’s family. C. A client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure, as the nurse had previously promised. D. A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively.

Correct Answer is D

Explanation

Choice A rationale

This choice represents the ethical principle of autonomy, which respects the client’s rights and preferences in their healthcare decisions.

Choice B rationale

This choice demonstrates the ethical principle of fidelity, which involves keeping promises and commitments, such as honoring a DNR order.

Choice C rationale

This choice reflects the ethical principle of beneficence, which involves taking positive actions to help others and promote the well-being of clients.

Choice D rationale

This choice represents the ethical principle of veracity, which involves truth-telling. In this situation, the nurse is being truthful to the client about their cancer diagnosis, thus demonstrating veracity.

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A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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A nurse is administering fluids to a client.
Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?