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: Assessment is the first and most important phase of the nursing process, as it involves collecting and analyzing data about the patient's health status, needs, and preferences. The nurse should have assessed the patient's blood pressure before administering the antihypertensive medication, as it could have been contraindicated or required a dosage adjustment. By failing to do so, the nurse put the patient at risk of hypotension and its complications.
Choice B reason: Planning is the second phase of the nursing process, in which the nurse sets goals and outcomes for the patient's care and selects appropriate interventions. The nurse did not make an error in this phase, as the administration of the antihypertensive medication was part of the plan of care for the patient with hypertension.
Choice C reason: Diagnosis is the third phase of the nursing process, in which the nurse identifies the patient's actual or potential health problems based on the assessment data. The nurse did not make an error in this phase, as the diagnosis of hypertension was accurate and supported by the patient's history and vital signs.
Choice D reason: Evaluation is the fourth and final phase of the nursing process, in which the nurse measures the patient's progress and outcomes and modifies the plan of care as needed. The nurse did not make an error in this phase, as the re-checking of the blood pressure and the recognition of the patient's symptoms were part of the evaluation process. However, the nurse should have also notified the provider and implemented interventions to treat the hypotension.
Correct Answer is D
Explanation
Choice A reason: Using soap to clean the client's skin is not a recommended action, as it can dry out and irritate the skin, increasing the risk of skin breakdown and infection.
Choice B reason: Applying friction when drying the client's skin is not a recommended action, as it can damage and abrade the skin, causing pain and inflammation.
Choice C reason: Using hot water to clean the client's skin is not a recommended action, as it can increase the blood flow and inflammation to the skin, as well as remove the natural oils that protect the skin.
Choice D reason: Applying a barrier cream to the client's skin is a recommended action, as it can moisturize and protect the skin from the effects of urine, such as acidity, bacteria, and enzymes.
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