A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?
Bradycardia
Distended neck veins
weight loss
Bradypnea
The Correct Answer is B
Rationale:
A. Bradycardia: Bradycardia is not a typical adverse effect of IV fluid therapy. If anything, fluid overload might contribute to hypertension or reflex tachycardia rather than a slowing of the heart rate.
B. Distended neck veins: Distended neck veins are a common sign of fluid volume overload, a potential adverse effect of IV therapy. This occurs when excess fluid increases venous pressure and can indicate worsening heart function or pulmonary congestion.
C. Weight loss: IV fluid therapy is expected to increase or stabilize weight due to fluid retention, not cause weight loss. Weight loss might instead indicate dehydration or catabolic states, not an adverse reaction to fluid infusion.
D. Bradypnea: Bradypnea is not typically caused by IV fluid therapy. In fluid overload, the more common respiratory symptom is tachypnea or dyspnea due to pulmonary congestion, not a slowed respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "The proxy should manage legal issues for the client." A health care proxy designated through a durable power of attorney for health care is authorized to make medical not legal decisions. Legal affairs typically require a separate legal power of attorney.
B. "The proxy can make treatment decisions if the client is under anesthesia." The health care proxy is activated when the client is unable to make decisions for themselves, including temporary incapacity such as being under general anesthesia. This ensures continuity of care and respects the client’s wishes.
C. "The proxy should make health care decisions for the client regardless of the client's ability to do so." The proxy only steps in when the client is deemed incapacitated. If the client is alert and competent, they retain the right to make all decisions about their care.
D. "The proxy can make financial decisions if the need arises." A health care proxy does not have authority over financial matters. Financial decisions are managed through a separate durable power of attorney for finances, not through a health care DPAHC.
Correct Answer is D,A,B,C
Explanation
Rationale:
A. Insert the catheter until resistance is felt: The catheter should be gently advanced into the tracheostomy tube until resistance is met, which typically indicates reaching the carina.
B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch): Slight withdrawal prevents trauma to the carina and positions the catheter optimally for effective suctioning.
C. Rotate the catheter while suctioning: Rotating the catheter as suction is applied allows for even clearing of secretions along the tracheal walls and helps prevent localized tissue damage.
D. Lubricate the catheter with sterile saline: Lubrication ensures smooth insertion and reduces trauma to the tracheal mucosa. This is the first action after applying sterile gloves.
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