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

After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.

Choice B rationale

Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.

Choice C rationale

Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

Choice D rationale

Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

A. “I feel a dull ache in my stomach.”. B. “I notice that the pain intensifies after I eat.”. C. “The pain is causing me to feel nauseous.”. D. “I’m experiencing mild pain.”.

Correct Answer is A

Explanation

The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.

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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

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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?