A nurse is collecting data from a client who has hyperparathyroidism and is receiving 0.9% sodium chloride via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?
New onset of hearing loss
Kussmaul respirations
Hyperthermia
Chvostek's sig
The Correct Answer is D
Rationale:
A. New onset of hearing loss: Hearing loss is not a typical adverse effect of 0.9% sodium chloride infusion. It may occur with high-dose loop diuretics like furosemide but is unrelated to isotonic fluid administration or hyperparathyroidism management.
B. Kussmaul respirations: These are deep, rapid respirations seen in metabolic acidosis, particularly diabetic ketoacidosis. They are not associated with isotonic fluid infusion or calcium disturbances in hyperparathyroidism.
C. Hyperthermia: Elevated body temperature is not linked to 0.9% sodium chloride infusion. Hyperthermia may occur with infections or neurologic injury, but not as a direct consequence of isotonic fluid therapy.
D. Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, which can occur as an adverse effect of 0.9% sodium chloride infusion in clients with hyperparathyroidism. Large volumes of saline increase calcium excretion, potentially leading to low serum calcium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.
B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.
C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.
D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.
Correct Answer is D
Explanation
Rationale:
A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.
B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.
C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.
D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.
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