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 C

Explanation

Choice A rationale

While the top of the cane should be parallel to the client’s greater trochanter, this alone does not indicate correct use of the cane.

Choice B rationale

Advancing the cane 46 cm (18 in) forward while walking is too far. To maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time.

Choice C rationale

The client should hold the cane on the stronger side of their body to increase support and maintain alignment. This is an indication of correct use.

Choice D rationale

The client should move their weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.

A. Hypertension B. Hypotension C. Tachycardia D. Bradycardia

Correct Answer is C

Explanation

Choice A rationale

Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.

Choice B rationale

Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.

Choice C rationale

Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.

Choice D rationale

Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.

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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 assessing a patient’s ability to use a walking cane.Which of the following observations would indicate that the patient is using the cane correctly?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?