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?
Bradypnea
Distended neck veins
Weight loss
Bradycardia
The Correct Answer is B
A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Desired dose = 50 mcg
Available strength = 0.025 mg/tablet
- Convert desired dose to milligrams (mg):
1 mg = 1000 mcg
50 mcg / 1000 mcg/mg = 0.05 mg
- Calculate the number of tablets:
Number of tablets = Desired dose (mg) / Available strength (mg/tablet)
= 0.05 mg / 0.025 mg/tablet
= 2 tablets
Correct Answer is D
Explanation
A. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast." The breast is rarely fully emptied during a feeding. Infants should be allowed to feed on one side until they naturally release it, ensuring they receive the nutrient-rich hindmilk.
B. "Manually expressing my milk will decrease my milk supply." Manual expression, like breastfeeding, stimulates milk production. Regularly removing milk from the breasts actually helps maintain or increase supply, especially during periods of engorgement or separation.
C. “My baby should always start on the same breast when feeding.” Alternating the starting breast with each feeding ensures even stimulation and drainage of both breasts. Always starting on the same side could lead to engorgement or reduced supply in the unused breast.
D. “The more my baby is at the breast sucking the more milk I will produce.” Breast milk production is based on a supply and demand mechanism. The more frequently and effectively the baby nurses, the more milk the body is signaled to produce.
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