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 D,B,C,A
Explanation
D. Rolls from back to side usually occurs around 4 months of age as the infant begins developing trunk strength.
B. Rolls from back to abdomen typically follows at around 5 to 6 months, indicating improved coordination and strength.
C. Sits steadily unsupported usually develops around 8 months, showing advanced balance and postural control.
A. Changes from prone to sitting is a more complex skill that typically appears around 10 months, requiring significant core strength and motor planning.
Correct Answer is B
Explanation
A. Wear clothing with zippers instead of buttons. This may be helpful for caregivers or for promoting independence in dressing, but it does not directly enhance safety in the home for a client with Alzheimer’s disease.
B. Place locks at the tops of exterior doors. Clients with Alzheimer’s are at risk for wandering, especially in later stages. Placing locks at the tops of doors helps prevent elopement while still allowing caregivers to control access, thus enhancing home safety.
C. Replace the carpet with hardwood floors. Carpets can actually provide more traction and cushioning than hardwood, which may be slippery and increase the risk of falls. Removing carpet is not necessary and could reduce safety.
D. Encourage physical activity prior to bedtime. Physical activity is beneficial but should be scheduled earlier in the day, as exercise close to bedtime may increase stimulation and interfere with sleep, which is already often disrupted in Alzheimer’s clients.
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