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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Expect to have a rapid pulse rate for the first few weeks: A newly implanted ICD does not cause a rapid heart rate. In fact, it monitors for dangerous rhythms and delivers a shock if one is detected. A rapid pulse could signal a complication and should be reported immediately.
B. Return in two weeks for a follow-up MRI: MRIs are generally contraindicated unless the ICD is MRI-compatible, which is not always the case. Strong magnetic fields can interfere with the device, so alternative imaging is typically used unless cleared by a cardiologist.
C. Resume tub baths and swimming after 24 hr: Clients should avoid submerging the incision site in water until it is fully healed, typically after several weeks. Early immersion increases the risk of infection at the surgical site.
D. Wear loose-fitting clothing: Loose clothing prevents irritation and pressure on the incision site during the healing process. It also helps reduce discomfort and lowers the risk of disturbing the ICD leads or dressing.
Correct Answer is B
Explanation
Rationale:
A. Probiotics: Probiotics are used to support gastrointestinal and immune health and do not significantly affect blood pressure or pose a known risk for intraoperative hypotension.
B. Black Cohosh: Black cohosh is often used to manage menopausal symptoms and is known to cause vasodilation, which can lower blood pressure. When combined with anesthetic agents, it can potentiate hypotensive effects during surgery.
C. Soy: Soy is consumed for its phytoestrogenic effects but does not have a direct or significant hypotensive action that increases surgical risk. Its impact on intraoperative blood pressure is minimal.
D. Flaxseed: Flaxseed may offer mild antihypertensive effects over time due to its omega-3 content, but it is not typically associated with clinically significant drops in blood pressure during surgery.
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