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
The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.
Correct Answer is A
Explanation
Choice A rationale
If a patient with a living will arrived at the emergency department with difficulty breathing, the healthcare team would provide immediate care to ease the patient’s distress, such as administering oxygen.
Choice B rationale
While a living will outlines a patient’s wishes for end-of-life care, it does not prevent the patient from receiving immediate, necessary care in an emergency situation.
Choice C rationale
Inserting a breathing tube may be necessary in some cases, but it would not be the first step in managing difficulty breathing.
Choice D rationale
While the healthcare team would consult the person appointed by the patient’s healthcare proxy to make decisions, immediate care would not be delayed.
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