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 A
Explanation
A. Choose a vein that is palpable and straight. A palpable, straight vein provides the best access for successful IV catheter insertion. It allows for easier threading of the catheter and reduces the risk of complications like infiltration.
B. Select a site on the client's dominant arm. The non-dominant arm is usually preferred to minimize interference with daily activities and reduce the risk of dislodgement due to frequent use.
C. Elevate the client's arm prior to insertion. Elevating the arm can decrease venous filling, making veins less prominent and harder to access. Instead, the arm should be placed in a dependent position to promote vein distention.
D. Apply a tourniquet below the venipuncture site. The tourniquet should always be placed above the insertion site to restrict venous return and make the veins more prominent and easier to access.
Correct Answer is B
Explanation
A. Providing a needle exchange program is considered secondary prevention, as it reduces complications in those already using substances rather than preventing initial use.
B. Teaching fifth graders about the risks of substance use is primary prevention, because it aims to stop substance use before it begins.
C. Giving a list of outpatient support services to clients leaving inpatient treatment is tertiary prevention, since it helps prevent relapse in those already affected.
D. Educating pregnant clients who are already in a sober living community is also not primary prevention, because they have a history of substance use; this falls under secondary/tertiary prevention.
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