A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?
A
B
C
D
The Correct Answer is B
Rationale:
A: This shows the IV insertion site on the hand. While important for checking infiltration or phlebitis, it does not affect flow rate or volume delivered, so it's not the priority in fluid overload.
B: This shows the IV drip chamber. This is the first place to assess because it allows the nurse to determine how fast the IV fluid is infusing. It provides a quick visual cue of the actual flow rate, which is essential in evaluating whether the infusion is too fast, the likely cause of the overload.
C: This is the IV tubing near the insertion site. Kinks or dislodgement can affect flow, but it’s not the most immediate concern when fluid overload is suspected.
D: Shows the roller clamp, this directly controls the flow rate in a gravity system, so it is the place to intervene when fluid overload is suspected. After assessing the flow rate in the drip chamber and confirming fast infusion, the nurse should adjust the flow rate at this part.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Platelet count: Platelets are primarily responsible for clotting, not infection response. While important for monitoring bleeding risk, they do not provide relevant information about infection or inflammation.
B. Neutrophil count: Neutrophils are the primary white blood cells involved in fighting bacterial infections. An elevated neutrophil count (neutrophilia) supports the presence of infection, making this value essential to report alongside purulent drainage.
C. Serum sodium level: Sodium levels reflect fluid and electrolyte balance but are not directly related to signs of infection or wound complications. This value is not the immediate priority in the context of purulent drainage.
D. Hematocrit: Hematocrit indicates the proportion of red blood cells and is useful in evaluating anemia or fluid status, but it does not provide insight into infection or wound healing.
Correct Answer is A
Explanation
Rationale:
A. Muscle pain: Muscle pain can signal myopathy or rhabdomyolysis, a serious adverse effect of statins that may lead to kidney damage due to muscle breakdown. This symptom requires immediate evaluation to prevent potentially life-threatening complications.
B. Diarrhea and flatulence: These are common gastrointestinal side effects of lovastatin and are usually mild and self-limiting. They do not require urgent intervention unless severe or persistent.
C. Abdominal cramps: Mild abdominal cramping can occur with statin use, often due to GI irritation. While uncomfortable, it is not usually urgent unless accompanied by other severe symptoms like jaundice or persistent nausea.
D. Altered taste: Changes in taste perception may occur with some medications, including statins, but are not typically dangerous. This symptom can affect quality of life but does not indicate an immediate threat.
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