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. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.
Correct Answer is C
Explanation
A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.