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?
Bradypnea
Distended neck veins
Weight loss
Bradycardia
The Correct Answer is B
A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.
Correct Answer is C
Explanation
A. Apply splints to the child's extremities during the day. Splints are typically used at night to help prevent joint contractures and support proper alignment during rest. Daytime use may limit mobility and physical activity, which are encouraged.
B. Encourage the child to take naps during the day. While rest is important, excessive daytime napping can contribute to joint stiffness and reduced function. Activity and movement are encouraged to maintain joint flexibility.
C. Have the child take a tub bath each morning. Warm baths help relieve joint stiffness and pain associated with juvenile idiopathic arthritis. Morning bathing is especially beneficial to improve mobility at the start of the day.
D. Keep the child on bedrest as long as pain persists. Prolonged bedrest can lead to muscle atrophy, stiffness, and joint contractures. Maintaining activity, as tolerated, is key to managing symptoms and preserving joint function.
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