A nurse is monitoring a client who has a head injury and is receiving mannitol 25% via IV infusion. The nurse should identify which of the following as an adverse effect of the medication and report to the provider?

Glasgow coma scale rating of 15

Crackles on auscultation

Increase in urinary output

Intracranial pressure reading of 12mm

Answer and Explanation

The Correct Answer is B

A. Glasgow Coma Scale rating of 15: A Glasgow Coma Scale (GCS) rating of 15 is a positive sign indicating that the client is fully conscious and oriented. It is not an adverse effect of mannitol.
B. Crackles on auscultation: Crackles, also known as rales, can indicate fluid overload or pulmonary edema, which can be an adverse effect of mannitol. Mannitol can cause shifts of fluid, including into the lungs, leading to pulmonary edema.
C. Increase in urinary output: Mannitol is an osmotic diuretic, and an increase in urinary output is an expected and therapeutic effect of the medication. It is not considered an adverse effect.
D. Intracranial pressure reading of 12 mmHg: A decrease in intracranial pressure is a therapeutic effect of mannitol, and a reading of 12 mmHg is generally within a normal range. It is not considered an adverse effect.

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Correct Answer is D

Explanation

A. Dark amber urine:
Dark amber urine is not typically an adverse effect of receiving 0.9% sodium chloride solution. It may be a sign of concentrated urine, dehydration, or the presence of certain substances, but it is not a direct adverse effect of the solution itself.
B. Decreased skin turgor:
Decreased skin turgor is a clinical manifestation of dehydration and is not an adverse effect of 0.9% sodium chloride solution. The solution is administered to address dehydration and restore fluid balance.
C. Increased bowel sounds:

Increased bowel sounds are not an adverse effect of 0.9% sodium chloride solution. Bowel sounds are influenced by various factors, including the presence of gas and peristalsis, but they are not directly related to the administration of this isotonic solution.
D. Pink, frothy sputum:
This is the correct answer. Pink, frothy sputum is a potential sign of pulmonary edema, which can be associated with fluid overload. Administering 0.9% sodium chloride solution too rapidly or in excessive amounts can lead to fluid overload and pulmonary edema.

A. Transparent membrane dressing B. Hydrocolloid dressing C. Sterile gauze bandage D. Adhesive bandage

Correct Answer is A

Explanation

A. Transparent membrane dressing:
This is the correct answer. Transparent dressings are commonly used to cover peripheral IV catheter insertion sites. They provide a clear view of the site, allow for easy monitoring, and create a barrier against contamination while maintaining a moist environment.

B. Hydrocolloid dressing:
Hydrocolloid dressings are generally used for wounds with minimal exudate. They are not typically used for securing peripheral IV catheters.

C. Sterile gauze bandage:
Sterile gauze bandages may be used for specific types of wounds but are not the preferred choice for covering peripheral IV catheter sites. Gauze dressings may increase the risk of contamination and do not provide a clear view of the site.

D. Adhesive bandage:
Adhesive bandages (commonly known as band-aids) are not suitable for covering peripheral IV catheter sites. They are typically used for small wounds or cuts.

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A nurse is monitoring a client who has a head injury and is receiving mannitol 25% via IV infusion. The nurse should identify which of the following as an adverse effect of the medication and report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving 0.9% sodium chloride solution to treat dehydration. Which of the following findings should the nurse identify as an adverse effect of the solution?

Correct Answer is D

Explanation

A nurse is caring for a client who has a peripheral IV catheter and a prescription for IV fluid replacement. The nurse should cover the Insertion site with which of the following types of dressing?

Correct Answer is A

Explanation

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