A nurse is caring for a client who is receiving 0.9% sodium chloride solution to treat dehydration. Which of the following findings should the nurse identify as an adverse effect of the solution?
Dark amber urine
Decreased skin turgor
Pink, frothy sputum
Increased bowel sounds
The Correct Answer is C
Choice A Reason:
Dark amber urine is incorrect. Dark urine can indicate concentrated urine, often seen in dehydration when the body is trying to conserve water.
Choice B Reason:
Decreased skin turgor is incorrect. Decreased skin turgor is a classic sign of dehydration, indicating that the skin lacks elasticity due to insufficient fluid intake or loss.
Choice C Reason:
Pink, frothy sputum is correct. Normal saline is a common intravenous solution used to treat dehydration. However, in some cases, especially when administered in excessive amounts, it can lead to fluid overload or pulmonary edema. This can manifest as pink, frothy sputum, indicating potential pulmonary congestion or edema, which is a serious adverse effect of fluid overload.
Choice D Reason:
Increased bowel sounds is incorrect. Increased bowel sounds can be seen in various conditions, including gastrointestinal disturbances or hyperactive bowel motility, but it's not typically associated with the adverse effects of normal saline administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Dark amber urine is incorrect. Dark urine can indicate concentrated urine, often seen in dehydration when the body is trying to conserve water.
Choice B Reason:
Decreased skin turgor is incorrect. Decreased skin turgor is a classic sign of dehydration, indicating that the skin lacks elasticity due to insufficient fluid intake or loss.
Choice C Reason:
Pink, frothy sputum is correct. Normal saline is a common intravenous solution used to treat dehydration. However, in some cases, especially when administered in excessive amounts, it can lead to fluid overload or pulmonary edema. This can manifest as pink, frothy sputum, indicating potential pulmonary congestion or edema, which is a serious adverse effect of fluid overload.
Choice D Reason:
Increased bowel sounds is incorrect. Increased bowel sounds can be seen in various conditions, including gastrointestinal disturbances or hyperactive bowel motility, but it's not typically associated with the adverse effects of normal saline administration.
Correct Answer is A
Explanation
Choice A Reason:
Rotate the application site every week is correct. Rotating the application site is essential to prevent skin irritation or sensitization. Advising the client to apply the patch to a different area of clean, dry, non-hairy skin each time helps reduce the risk of skin irritation at the application site.
Choice B Reason:
The transdermal patch can cause insomnia is incorrect. Insomnia is a potential side effect of nicotine replacement therapy (NRT) patches, including transdermal nicotine patches, but it's not a universal side effect for everyone using the patch.
Choice C Reason:
Leave the patch in place for 8 hr. each day is incorrect. Transdermal nicotine patches are typically worn for 16–24 hours each day, depending on the specific product instructions. Leaving the patch on for a shorter duration might reduce its effectiveness in supporting smoking cessation.
Choice D Reason:
The transdermal patch releases nicotine rapidly into the bloodstream is incorrect. Transdermal nicotine patches deliver nicotine slowly through the skin into the bloodstream over an extended period rather than providing a rapid release. This gradual release helps reduce cravings and withdrawal symptoms associated with smoking cessation.
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