A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

Bradycardia

Distended neck veins

weight loss

Bradypnea

Answer and Explanation

The Correct Answer is B

Rationale:

A. Bradycardia: Bradycardia is not a typical adverse effect of IV fluid therapy. If anything, fluid overload might contribute to hypertension or reflex tachycardia rather than a slowing of the heart rate.

B. Distended neck veins: Distended neck veins are a common sign of fluid volume overload, a potential adverse effect of IV therapy. This occurs when excess fluid increases venous pressure and can indicate worsening heart function or pulmonary congestion.

C. Weight loss: IV fluid therapy is expected to increase or stabilize weight due to fluid retention, not cause weight loss. Weight loss might instead indicate dehydration or catabolic states, not an adverse reaction to fluid infusion.

D. Bradypnea: Bradypnea is not typically caused by IV fluid therapy. In fluid overload, the more common respiratory symptom is tachypnea or dyspnea due to pulmonary congestion, not a slowed respiratory rate.

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Correct Answer is B

Explanation

Rationale:

A. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers are not appropriate as an immediate response to sudden nausea. The priority is to relieve the symptom, which may be related to positional compression of major blood vessels.

B. Position the client on her side: At 36 weeks gestation, the gravid uterus can compress the inferior vena cava when lying supine, leading to supine hypotensive syndrome. Symptoms like nausea, dizziness, and hypotension can occur. Side-lying positioning relieves the pressure and restores venous return and cardiac output.

C. Administer propranolol IV to the client: Propranolol is not indicated for treating pregnancy-related nausea or hypotension. Using it without a cardiovascular diagnosis would be inappropriate and could worsen hypotensive symptoms.

D. Ask the client to increase her daily calcium intake: While calcium is essential in pregnancy, especially for fetal bone development, increasing calcium intake has no immediate impact on sudden nausea or circulatory symptoms linked to maternal positioning.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Rationale for correct choices:

Apply oxygen via nasal cannula: The client’s oxygen saturation levels of 87–88% on room air indicate moderate to severe hypoxemia, requiring immediate correction. Since the client has a history of COPD and is post-MI, improving oxygenation is essential to reduce myocardial workload and prevent further ischemia or respiratory distress.
Initiating a consult for cardiac rehabilitation: Once the client's immediate needs are stabilized, early initiation of cardiac rehabilitation is appropriate. This supports physical recovery, promotes lifestyle changes like smoking cessation and exercise, and reduces future cardiac risk.

Rationale for incorrect choices:

Administer a second dose of nitroglycerin: The client’s chest pain has resolved following the initial dose, so there is no current indication to give a second dose. Re-administering nitroglycerin unnecessarily can lead to hypotension or reflex tachycardia, especially risky in a post-MI patient.
Request a prescription for a PRN anxiolytic: The client has already been prescribed alprazolam 0.5 mg three times daily, and their anxiety has improved. Requesting an additional anxiolytic is unnecessary at this point and does not address the more urgent issue of low oxygen saturation.
Requesting a prescription for a WBC count: There are no signs or symptoms of infection such as fever, chills, or elevated WBC to justify this request. The focus should remain on the client’s cardiopulmonary status and rehabilitation rather than diagnostics that are not clinically indicated.
Administering a bolus of fluids: There is no clinical indication of fluid volume deficit, hypotension, or dehydration. Administering fluids to a post-MI patient with COPD may lead to fluid overload, pulmonary edema, or increased myocardial strain.

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A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse on a step-down unit is admitting a client. Exhibits Complete the following sentence by using the lists of options. The nurse should first dropdown followed by dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

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