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 C
Explanation
A. "You should make sure your partner takes the prescribed medication." While medication adherence is important, this response shifts the focus to advice-giving rather than exploring the partner’s emotions or current experience, which limits therapeutic communication.
B. "You did the right thing by bringing your partner in for treatment." Although supportive, this statement closes off the conversation and doesn’t invite the partner to share more about their feelings or the situation at home.
C. "Can you talk about what was happening with your partner at home?" This open-ended, therapeutic response encourages the partner to express their thoughts and emotions, facilitating a better understanding of the client’s condition and the impact it has had on the family.
D. "Why do you think your partner's symptoms are progressing so quickly?" Asking “why” can feel accusatory or put the partner on the defensive. It may also imply blame, which is not helpful in building trust or gathering therapeutic insight.
Correct Answer is D
Explanation
A. Explain long term consequences of the procedure to the child. This level of detail is not developmentally appropriate for a school-age child. It may increase anxiety without helping the child understand or cope with the immediate situation.
B. Remove the dressings while explaining the procedure to the child. While it is important to explain procedures, it should be done before starting to allow time for questions and emotional preparation. Explaining during may cause confusion or distraction.
C. Keep equipment out of the child's sight. Hiding equipment can actually increase fear and mistrust. School-age children benefit from open, age-appropriate communication and preparation about what to expect.
D. Allow the child to help remove the dressings. This is the most appropriate action. Allowing the child to participate in their care provides a sense of control, reduces anxiety, and helps build trust. It also aligns with the developmental need of school-age children to take on increasing responsibility and be involved in decision-making.
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