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 C
Explanation
Choice A reason: This is not the correct answer because reassessing the patient is not the next step after completing an assessment. Reassessment is done periodically or when there is a change in the patient's condition, but not immediately after the initial assessment.
Choice B reason: This is not the correct answer because writing nursing interventions is not the next step after completing an assessment. Nursing interventions are the actions that the nurse plans and implements to achieve the desired outcomes for the patient. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Choice C reason: This is the correct answer because analyzing cues is the next step after completing an assessment. Analysis is the process of identifying patterns, relationships, and trends in the assessment data, and comparing them with the normal and expected findings. Analysis helps the nurse to identify the patient's problems, needs, strengths, and risks.
Choice D reason: This is not the correct answer because creating SMART goals is not the next step after completing an assessment. SMART goals are the specific, measurable, achievable, realistic, and time-bound outcomes that the nurse and the patient agree on. They are based on the nursing diagnoses, which are derived from the analysis of the assessment data.
Correct Answer is D
Explanation
Choice A reason: Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.
Choice B reason: Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.
Choice C reason: Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.
Choice D reason: Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today