A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
Metallic taste in mouth
Abdominal fullness
Feeling flushed and warm
Swollen lips
The Correct Answer is D
A. A metallic taste in the mouth is a common side effect of the contrast dye used in IV urography procedures and is not typically a cause for concern.
B. Abdominal fullness may occur due to the administration of fluids during the procedure and is not usually a priority finding unless it persists or is severe.
C. Feeling flushed and warm may be a transient reaction to the contrast dye and does not typically require immediate intervention unless accompanied by other symptoms.
D. Swollen lips could indicate an allergic reaction to the contrast dye, which can progress rapidly and potentially lead to a severe reaction such as anaphylaxis. This is the priority finding requiring immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Serum calcium levels are not directly indicative of hypervolemia.
B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.
C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.
D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.
Correct Answer is A
Explanation
A. Decreased reflexes can indicate electrolyte imbalance, particularly hypokalemia, which is a common adverse effect of loop diuretics. Low potassium levels can affect neuromuscular function and should be reported and addressed promptly.
B. A weight gain of 1.4 kg (3 lb) suggests fluid retention and worsening heart failure, not an adverse effect of the diuretic. Loop diuretics are expected to promote weight loss through fluid removal.
C. Increased urinary output is an expected therapeutic effect of a loop diuretic and indicates the medication is working as intended.
D. Jugular vein distention reflects fluid volume overload associated with heart failure rather than an adverse medication effect.
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