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 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.
Correct Answer is B
Explanation
A. Bruxism: Bruxism, or teeth grinding, is a potential adverse effect of citalopram but is generally less severe than confusion. While it should be monitored and reported if severe or persistent, it is not typically considered a priority adverse effect.
B. Confusion: Confusion can indicate a serious adverse reaction or complication, such as serotonin syndrome, which is a potentially life-threatening condition associated with the use of selective serotonin reuptake inhibitors (SSRIs) like citalopram. Therefore, confusion is the priority adverse effect to report to the provider.
C. Insomnia: Insomnia is a common side effect of citalopram and other SSRIs but is generally less severe than confusion. It should be monitored and reported if severe or persistent, but it is not typically considered a priority adverse effect.
D. Weight loss: Weight loss can occur as a side effect of citalopram but is generally less severe than confusion. It should be monitored and reported if excessive or rapid, but it is not typically considered a priority adverse effect.
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