A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?
There are crackles throughout both lung fields.
The patient's radial pulse is 105 beats/min.
There is sediment and blood in the patient's urine
The blood pressure increases from 66/50 to 122/74 mm
The Correct Answer is A
A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.
The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.
The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.
An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.
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Correct Answer is B
Explanation
Opioid tolerance occurs when the body becomes less responsive to the effects of opioids over time. This means that higher doses of the medication are needed to achieve the same level of pain relief that was previously achieved with lower doses. Opioid tolerance is a common phenomenon in long-term opioid therapy and can occur in patients who have been using opioids for an extended period.
Opioid abstinence syndrome, also known as opioid withdrawal, refers to the set of symptoms that occur when a person abruptly stops or reduces their use of opioids after developing physical dependence.
Opioid toxicity refers to the harmful effects that occur when an individual takes an excessive dose of opioids, leading to potentially life-threatening complications. It is characterized by symptoms such as respiratory depression, sedation, pinpoint pupils, and decreased level of consciousness.
Opioid addiction is a complex condition characterized by compulsive drug-seeking behavior, loss of control over opioid use, and continued use despite negative consequences.
Correct Answer is C
Explanation
Nitroprusside is a potent vasodilator medication used to rapidly reduce blood pressure in hypertensive emergencies. Its primary action is to dilate blood vessels, leading to a decrease in systemic vascular resistance and subsequent reduction in blood pressure.
Monitoring the client's blood pressure is crucial during the administration of nitroprusside to ensure that the medication is achieving the desired effect and that blood pressure is being appropriately controlled. The nurse will assess blood pressure frequently to adjust the infusion rate and titrate the medication to achieve the desired therapeutic effect while avoiding hypotension or other adverse effects.
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