A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?
The client prefers IV therapy over oral fluids.
The client has a history of IV drug use.
The client is unable to tolerate oral intake.
The client's family requested IV therapy.
The Correct Answer is C
A) This choice is incorrect because the client's preference for IV therapy over oral fluids is not a valid indication for initiating IV therapy. Clinical indications should guide the decision, not personal preferences.
B) This choice is incorrect because a history of IV drug use does not automatically indicate a need for IV therapy for dehydration. The client's current condition and clinical status should determine the need for IV fluids.
C) This choice is correct. In cases of severe dehydration where the client is unable to tolerate oral intake, IV therapy is essential to provide rapid rehydration and restore fluid and electrolyte balance.
D) This choice is incorrect because the family's request alone is not a sufficient indication for initiating IV therapy. The decision should be based on the client's clinical condition and medical needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not associated with chest pain, dyspnea, and tachycardia.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with chest pain, dyspnea, and tachycardia.
C) This choice is incorrect because fluid overload does not typically cause chest pain, dyspnea, and tachycardia but rather manifests as symptoms such as elevated blood pressure, jugular vein distention, and edema.
D) This choice is correct. The client's symptoms of chest pain, dyspnea, and tachycardia are potential signs of thrombophlebitis, which is the inflammation of a vein associated with the formation of a blood clot. The clot can become dislodged and travel to the lungs, leading to a pulmonary embolism, which presents with chest pain and dyspnea.
Correct Answer is D
Explanation
A) This choice is incorrect because infiltration involves the inadvertent administration of IV fluid into the surrounding tissues and is not typically associated with systemic symptoms like fever, tachycardia, and hypotension.
B) This choice is incorrect because phlebitis typically presents with localized symptoms around the insertion site and is not associated with systemic symptoms like fever, tachycardia, and hypotension.
C) This choice is incorrect because fluid overload is not associated with symptoms of fever, tachycardia, and hypotension. It is characterized by symptoms such as dyspnea and edema.
D) This choice is correct. The client's symptoms of fever, tachycardia, and hypotension are potential signs of sepsis, a severe infection that can occur as a complication of IV therapy. Sepsis is a life-threatening condition that requires immediate medical attention.
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