A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

Hyperglycemia

Hypovolemia

Hypercalcemia

Hypokalemia

Answer and Explanation

The Correct Answer is A

Choice A reason: An IV infusion of dextrose 10% in water can cause hyperglycemia, which is an elevated blood sugar
level.

Choice B reason: Hypovolemia, or decreased blood volume, is not a typical adverse effect of dextrose infusion.

Choice C reason: Hypercalcemia, or high calcium levels in the blood, is not associated with dextrose infusion.

Choice D reason: While dextrose infusion can affect electrolyte balance, hypokalemia, or low potassium levels, is not
the primary concern with dextrose infusion.

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Correct Answer is B

Explanation

Choice A reason: Looping the tubing on the client's bed can cause kinks and obstruct the drainage, which is not
recommended.

Choice B reason: Taping the connections on the chest tube is essential to maintain an airtight system and prevent air leaks, which is crucial for proper chest tube function.

Choice C reason: The chest tube drainage system should be placed below the level of the client's heart to facilitate gravity drainage, not above.

Choice D reason: Stripping the chest tube, which involves squeezing and pulling the tubing to clear clots, is not routinely recommended as it can generate negative pressure and damage tissue.

A. Substernal retractions noted on the client's chest. B. Crackles auscultated over the client's lung fields C. Crepitus palpated on the client's chest. D. Dullness percussed over the client's lung fields

Correct Answer is D

Explanation

Choice A reason: Substernal retractions are not typically associated with pleural effusion; they are more indicative of conditions causing increased work of breathing.

Choice B reason: Crackles are usually heard in conditions like pneumonia or heart failure, but not typically in isolated pleural effusion unless it is associated with other lung conditions.

Choice C reason: Crepitus is generally associated with subcutaneous emphysema when air is present in the
subcutaneous tissue and is not a common finding in pleural effusion.

Choice D reason: Dullness on percussion over the lung fields is a classic finding in pleural effusion due to the presence of fluid in the pleural space.

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A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

Nursing Test Bank

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