A nurse is administering fluids to a client.
Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?
Auscultate lung sounds
Measure urine output
Monitor blood pressure readings
Monitor electrolyte levels . .
The Correct Answer is A
Choice A rationale
Auscultating lung sounds is the priority when monitoring for adverse effects of administering IV fluids. Fluid overload can lead to pulmonary edema, which would be detected by abnormal lung sounds such as crackles.
Choice B rationale
While measuring urine output is important to assess kidney function and fluid balance, it is not the priority in this case.
Choice C rationale
Monitoring blood pressure readings is important when administering IV fluids, but it is not the priority in this case.
Choice D rationale
Monitoring electrolyte levels is important when administering IV fluids, but it is not the priority in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Walking briskly is a weight-bearing exercise that is essential for maintaining bone mass, which can help to prevent osteoporosis. Regular weight-bearing exercise, such as a 20-30-minute aerobic exercise, 3 times a week, is recommended for older adults at risk for osteoporosis.
Choice B rationale
Riding a bicycle is a non-weight-bearing exercise. While it can contribute to overall fitness and health, it does not provide the same benefits for bone health as weight-bearing exercises like walking.
Choice C rationale
Performing isometric exercises can help to strengthen muscles, but these exercises do not have the same impact on bone health as weight-bearing exercises.
Choice D rationale
Engaging in high-impact aerobics can be beneficial for bone health, but it may not be suitable for an older adult at risk for osteoporosis due to the increased risk of injury.
Correct Answer is A
Explanation
Choice A rationale
The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.
Choice B rationale
While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.
Choice C rationale
Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.
Choice D rationale
Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.
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