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 . .

Answer and Explanation

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.

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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.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².

Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.

Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.

Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.

Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a terminally ill patient about declining resuscitation in a living will.The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks: Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by the dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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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?