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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Explain long term consequences of the procedure to the child. This level of detail is not developmentally appropriate for a school-age child. It may increase anxiety without helping the child understand or cope with the immediate situation.
B. Remove the dressings while explaining the procedure to the child. While it is important to explain procedures, it should be done before starting to allow time for questions and emotional preparation. Explaining during may cause confusion or distraction.
C. Keep equipment out of the child's sight. Hiding equipment can actually increase fear and mistrust. School-age children benefit from open, age-appropriate communication and preparation about what to expect.
D. Allow the child to help remove the dressings. This is the most appropriate action. Allowing the child to participate in their care provides a sense of control, reduces anxiety, and helps build trust. It also aligns with the developmental need of school-age children to take on increasing responsibility and be involved in decision-making.

A. The client engages in quiet activities in their room. B. The client slept 5 hr the previous night. C. The client takes 2 short naps during the day. D. The client appears to listen to unseen others. E. The client consumes 8 oz of high-calorie fluids each hour.

Correct Answer is ["B","C","E"]

Explanation

A. The client engages in quiet activities in their room. While this may seem positive, it is not a reliable indicator of improvement in this context. It could suggest withdrawal or sedation rather than clinical stabilization. Further assessment would be needed to determine its significance.
B. The client slept 5 hr the previous night. This is a clear sign of improvement. The client had not slept for 2 days previously, and sleep is one of the first indicators of recovery in clients experiencing mania. Restorative sleep helps stabilize mood and reduce disorganized thinking.
C. The client takes 2 short naps during the day. Napping indicates the client is able to rest voluntarily, which contrasts with their earlier constant movement and hyperactivity. This suggests reduced mania-related agitation and increased capacity for rest.
D. The client appears to listen to unseen others. This behavior reflects ongoing hallucinations, which indicate that the client is still experiencing active psychosis. This is not an improvement and suggests further monitoring and treatment adjustment may be needed.
E. The client consumes 8 oz of high-calorie fluids each hour. Adequate nutrition and hydration are key components of recovery, especially since the client had been unable to recall their last meal and showed signs of dehydration. This is a positive sign of improved self-care and physical stability.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to change the dressings on a school-age child who has sustained multiple burns. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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