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 C

Explanation

Rationale:

A. Inject into the vastus lateralis: The preferred injection sites for insulin are subcutaneous areas such as the abdomen, upper arms, thighs, or buttocks. The vastus lateralis is used for intramuscular injections, not subcutaneous insulin administration.

B. Roll the syringe gently to ensure mixture of the insulins: Only the NPH (cloudy) insulin should be rolled gently between the hands to mix it evenly before drawing it up. The syringe itself should not be rolled after both insulins are inside, as this may affect accuracy.

C. Draw up regular insulin prior to NPH insulin: When mixing insulins, regular (clear) insulin should be drawn up first to avoid contaminating the vial of regular insulin with the cloudy NPH insulin, which could alter its action and absorption.

D. Use a 15 angle for the injection: Insulin is administered subcutaneously using a 45- to 90-degree angle, depending on the client’s body habitus. A 15-degree angle is too shallow and is used for intradermal injections, not subcutaneous ones.

A. Prenatal anemia B. Polyhydramnios C. High parity D. Prolonged rupture of membranes

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

Prenatal anemia: Anemia may impair immune function and tissue oxygenation, making the postpartum client more vulnerable to infections such as endometritis, especially after cesarean delivery.
Polyhydramnios: Excessive amniotic fluid stretches the uterus beyond normal capacity, which can impair uterine contractility postpartum, increasing the risk of uterine atony and resulting in subinvolution or hemorrhage.
High parity: Multiple previous pregnancies lead to uterine muscle fatigue, reducing tone and contractility, which predisposes the uterus to poor involution and increases the risk of uterine atony.

Prolonged rupture of membranes: A rupture lasting more than 18 hours increases the risk of ascending bacterial infection and is a significant risk factor for postpartum endometritis or chorioamnionitis.

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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

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about administering NPH insulin and regular insulin together in one injection. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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