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 A
Explanation
Choice A reason: This is the correct answer because it shows that the RN understands delegation as a way of managing time effectively. Delegation is the process of assigning tasks to other members of the health care team who are competent and qualified to perform them. By working with the LPN and nursing assistant on dividing up patient care tasks, the RN can ensure that the tasks are done safely, efficiently, and according to the scope of practice of each team member.
Choice B reason: This is not the correct answer because it shows that the RN does not understand delegation as a way of managing time effectively. Working overtime until everything is finished is not a sustainable or productive strategy, as it can lead to fatigue, burnout, and errors. The RN should prioritize the tasks that are most important and urgent, and delegate the tasks that can be done by others.
Choice C reason: This is not the correct answer because it shows that the RN does not understand delegation as a way of managing time effectively. Checking to make sure that the tasks are done correctly is part of the supervision and evaluation of delegation, but it is not the main goal of delegation. The main goal of delegation is to optimize the use of resources and skills of the health care team, and to provide quality care to the patients. The RN should trust and respect the abilities of the LPN and nursing assistant, and only intervene if there is a problem or a concern.
Choice D reason: This is not the correct answer because it shows that the RN does not understand delegation as a way of managing time effectively. Completing every nursing intervention or report by the end of the shift is not always possible or realistic, especially in a busy and dynamic health care environment. The RN should focus on the outcomes and quality of care, rather than the quantity of tasks. The RN should also communicate and collaborate with the other members of the health care team, and hand over any unfinished tasks to the next shift.
Correct Answer is B
Explanation
Choice A reason: This is not the correct answer because this statement by the client indicates that the client understands the dietary restrictions and guidelines that are necessary after bariatric surgery. A liquid/pureed diet and limited fluid intake are recommended to prevent complications such as nausea, vomiting, dehydration, and dumping syndrome.
Choice B reason: This is the correct answer because this statement by the client indicates that the client does not understand the importance of a thorough evaluation by the surgeon prior to the procedure. Bariatric surgery is a major surgery that involves significant risks and benefits, and requires careful consideration of the client's medical history, physical condition, psychological status, and readiness for lifestyle changes. The surgeon should assess the client's eligibility, suitability, and expectations for the surgery, and provide informed consent and education.
Choice C reason: This is not the correct answer because this statement by the client indicates that the client understands the basic principles and types of bariatric surgery. Bariatric surgery can be classified into restrictive, malabsorptive, or combined procedures, depending on how they affect the size of the stomach and the absorption of food. The most common types of bariatric surgery are gastric bypass, sleeve gastrectomy, and adjustable gastric banding.
Choice D reason: This is not the correct answer because this statement by the client indicates that the client understands the long-term implications and commitments of bariatric surgery. Bariatric surgery is not a quick fix or a magic solution for obesity, but rather a tool that helps the client achieve and maintain weight loss and improve health outcomes. The client should be aware that bariatric surgery requires lifelong changes in diet, exercise, medication, supplementation, and follow-up care.
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