A nurse is caring for a client who is dehydrated and receiving IV fluid replacement. The nurse should identify that which of the following findings indicates the treatment has been effective?
Increased heart rate
Excessive thirst
Moist oral mucous membranes
Decreased blood pressure
The Correct Answer is C
A. An increased heart rate can be a sign of dehydration and would not indicate that IV fluid replacement has been effective.
B. Excessive thirst is a symptom of dehydration and would not indicate that IV fluid replacement has been effective.
C. Moist oral mucous membranes indicate improved hydration status and are a positive response to IV fluid replacement.
D. Decreased blood pressure is a sign of dehydration and would not indicate that IV fluid replacement has been effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Peripheral edema: Peripheral edema is not a commonly reported adverse effect of paroxetine.
It is more commonly associated with medications such as calcium channel blockers and certain antihypertensive agents.
B. Alopecia: Alopecia, or hair loss, is not a commonly reported adverse effect of paroxetine. Hair loss is more commonly associated with certain chemotherapy agents and other medications.
C. Drowsiness: Drowsiness is a common side effect of paroxetine and other selective serotonin reuptake inhibitors (SSRIs). Clients should be advised to monitor for drowsiness, especially when starting the medication or adjusting the dosage. Drowsiness can affect activities such as driving or operating machinery and may indicate the need for dosage adjustment or medication change.
D. Tinnitus: Tinnitus, or ringing in the ears, is not a commonly reported adverse effect of paroxetine. It is more commonly associated with medications such as certain antibiotics (e.g., aminoglycosides) and high-dose aspirin.
Correct Answer is A
Explanation
A. Filing a report with the facility to document the incident as a near miss medication error is essential for tracking and investigating medication errors to prevent future occurrences.
B. While contacting the prescribing provider may be necessary, the priority is to report the error internally within the facility.
C. While documenting the nurse's actions is important, it is essential to report the error through the appropriate channels within the facility.
D. While informing the client about the error is necessary, the immediate action should be to report the error internally within the facility.
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