The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate?
Fluid volume deficit
Fluid volume excess
Speed shock
Pulmonary embolism
The Correct Answer is B
Choice A reason: Fluid volume deficit is a condition in which the body loses more fluid than it gains, resulting in dehydration, hypotension, and electrolyte imbalances. It is not a complication of IV fluid therapy, but rather a reason for initiating it.
Choice B reason: Fluid volume excess is a condition in which the body retains more fluid than it needs, resulting in edema, hypertension, and heart failure. It is a potential complication of IV fluid therapy, especially in older adults who have reduced renal function and cardiac output. The nurse's assessment findings of crackles, shortness of breath, and jugular vein distention are indicative of fluid overload and pulmonary congestion.
Choice C reason: Speed shock is a systemic reaction that occurs when a substance is administered too rapidly into the bloodstream, causing adverse effects such as chest pain, dyspnea, hypotension, and cardiac arrest. It is not a complication of IV fluid therapy, but rather a risk associated with IV medication administration.
Choice D reason: Pulmonary embolism is a blockage of one or more pulmonary arteries by a blood clot, fat, or air, causing impaired gas exchange, chest pain, dyspnea, and hemoptysis. It is not a complication of IV fluid therapy, but rather a possible outcome of venous thromboembolism, which can be prevented by using anticoagulants and mechanical devices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Nurses can accomplish more if they perform the easiest or fastest interventions is not a primary reason for prioritizing care. This statement implies that nurses should focus on the quantity rather than the quality of care. However, nurses should prioritize care based on the urgency and complexity of the patient's needs, not on the ease or speed of the interventions. Performing the easiest or fastest interventions may not address the most important or critical issues that the patient faces.
Choice B reason: Nurses should always perform interventions related to client preference early in the shift is not a primary reason for prioritizing care. This statement implies that nurses should base their care on the patient's wishes rather than the patient's condition. However, nurses should prioritize care based on the severity and acuity of the patient's problems, not on the patient's preference. Performing interventions related to client preference early in the shift may not be feasible or appropriate if the patient has more urgent or emergent needs that require immediate attention.
Choice C reason: Nurses need to plan how to accomplish all activities within one shift is not a primary reason for prioritizing care. This statement implies that nurses should focus on the completion rather than the quality of care. However, nurses should prioritize care based on the significance and impact of the patient's outcomes, not on the completion of the activities. Accomplishing all activities within one shift may not be possible or necessary if the patient's situation changes or if some activities can be delegated or postponed.
Choice D reason: Nurses have a limited amount of time to perform nursing interventions during a shift is a primary reason for prioritizing care. This statement acknowledges that nurses face time constraints and competing demands in their work environment. Therefore, nurses should prioritize care based on the best use of their time and resources to meet the patient's needs. Having a limited amount of time to perform nursing interventions during a shift requires nurses to make clinical judgments and decisions that optimize the patient's health and safety.
Correct Answer is B
Explanation
Choice A reason: Hypernatremia is a condition of high sodium levels in the blood. It can cause symptoms such as thirst, dry mouth, confusion, agitation, and seizures. It is not likely to cause postural hypotension, which is a drop in blood pressure when changing positions.
Choice B reason: Hyponatremia is a condition of low sodium levels in the blood. It can cause symptoms such as headache, nausea, vomiting, muscle weakness, fatigue, and confusion. It can also cause postural hypotension, as sodium helps regulate fluid balance and blood pressure.
Choice C reason: Hyperkalemia is a condition of high potassium levels in the blood. It can cause symptoms such as muscle weakness, paralysis, irregular heartbeat, and cardiac arrest. It is not likely to cause postural hypotension, which is more related to fluid and sodium levels.
Choice D reason: Hypokalemia is a condition of low potassium levels in the blood. It can cause symptoms such as muscle cramps, weakness, fatigue, constipation, and arrhythmias. It is not likely to cause postural hypotension, which is more related to fluid and sodium levels.
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