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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Email the client's health information to the facility in an unencrypted file: Sending unencrypted emails violates HIPAA standards, as it risks unauthorized access to protected health information. All electronic transmissions must be secured to ensure client confidentiality.

B. Fax the client's name and identifiable information to the rehabilitation: Faxing identifiable information can be permissible if proper safeguards are used, but without assurance of security or a cover sheet, this could breach confidentiality. It’s not the best initial action without those protections.

C. Discuss the client's response to the transfer with another staff nurse: Unless the other nurse is directly involved in the client’s care, this discussion is unnecessary and breaches confidentiality. Health information should only be shared on a need-to-know basis.

D. Provide a verbal report of the client's condition to the paramedic: Providing a verbal handoff to the paramedic is appropriate and necessary for continuity of care during transfer. It is a secure, direct communication method that supports both confidentiality and patient safety.

A. "Can you talk about what was happening with your partner at home?" B. "Why do you think your partner's symptoms are progressing so quickly?” C. "You should make sure your partner takes the prescribed medication” D. "You did the right thing by bringing your partner in for treatment”

Correct Answer is A

Explanation

Rationale:

A. "Can you talk about what was happening with your partner at home?": This open-ended question encourages the partner to express emotions and provide context, which helps build trust and gather relevant information. It’s a therapeutic response that validates the partner’s experience without judgment or assumptions.

B. "Why do you think your partner's symptoms are progressing so quickly?” This question may come off as accusatory or put the partner on the defensive. "Why" questions can create a sense of blame or pressure, which is not conducive to a supportive therapeutic environment.

C. "You should make sure your partner takes the prescribed medication”: This directive may be perceived as dismissive and does not acknowledge the partner’s emotional distress. While medication adherence is important, this is not the most therapeutic or empathetic initial response.

D. "You did the right thing by bringing your partner in for treatment”: While affirming the decision is supportive, this response closes the conversation and doesn’t invite the partner to explore their concerns or emotions further, limiting therapeutic dialogue.

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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?

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