A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

There are crackles throughout both lung fields.

The patient's radial pulse is 105 beats/min.

There is sediment and blood in the patient's urine

The blood pressure increases from 66/50 to 122/74 mm

Answer and Explanation

The Correct Answer is A

A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.

The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.

The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.

An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.

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Correct Answer is D

Explanation

Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.

Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.

A. Loss of privacy and control. B. Separation anxiety C. Fear of pain/bodily injury. D. Stranger anxiety.

Correct Answer is C

Explanation

School-age children typically have a growing awareness of their bodies and an understanding of potential harm or pain. They may fear procedures or treatments that involve physical discomfort, such as injections, blood draws, or invasive procedures. The fear of experiencing pain or bodily injury can cause anxiety and distress in school-age children.

It is important for the nurse to acknowledge and address the child's fear of pain or bodily injury by providing age-appropriate explanations, offering reassurance, and implementing strategies to minimize discomfort. This may involve using distraction techniques, providing emotional support, and ensuring proper pain management during procedures.

While loss of privacy and control, separation anxiety, and stranger anxiety can also be stressors for school-age children, the fear of pain or bodily injury is often a significant concern that may require specific attention and interventions from the nurse.

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A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings will the nurse anticipate in the client with cholelithiasis?

Correct Answer is D

Explanation

As a nurse caring for a school-age child, the nurse may anticipate which primary stressor/fear?

Correct Answer is C

Explanation

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