A nurse is discussing safety for administering intravenous fluids. Which condition might occur if hypertonic solutions are administered too quickly?

Choice A reason: Sudden abdominal pain is a sign of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. It occurs when the ulcer erodes through the wall of the stomach or duodenum, causing leakage of gastric contents into the peritoneal cavity. This causes inflammation, infection, and peritonitis.

Choice B reason: Hyperactive bowel sounds are not indicative of gastrointestinal perforation. They may be present in other conditions, such as gastroenteritis, intestinal obstruction, or diarrhea.

Choice C reason: Bradycardia is not indicative of gastrointestinal perforation. It may be caused by other factors, such as vagal stimulation, medication side effects, or cardiac disorders.

Choice D reason: Decreased blood pressure is not indicative of gastrointestinal perforation. It may be a result of other causes, such as hypovolemia, shock, or dehydration.

Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.

Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.

Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.

Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.