A patient is receiving a bolus of IV fluids for dehydration. During administration of the solution, it is most important for the nurse to carefully monitor:

lung sounds

skin turgor

temperature

thirst and dry mouth.

Answer and Explanation

The Correct Answer is A

A. lung sounds: Monitoring lung sounds is essential during IV fluid administration to detect signs of fluid overload, such as crackles, which may indicate pulmonary edema and require immediate intervention. This is especially critical in patients with compromised cardiac or renal function.

B. skin turgor: While skin turgor helps assess hydration status, it changes more slowly and does not indicate acute fluid shifts or overload during rapid fluid administration. It is more useful for evaluating chronic hydration status rather than immediate response to IV therapy.

C. temperature: Temperature monitoring is not a direct or sensitive indicator of fluid balance or the risk of fluid overload. Fever or hypothermia may signal infection or other systemic issues but does not reflect intravascular volume status during fluid replacement.

D. thirst and dry mouth: These are subjective signs of dehydration but are not reliable for monitoring the effects or complications of IV fluid therapy once it is initiated. Patient perception can vary and may not correlate with actual fluid status or ongoing needs.

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Correct Answer is B

Explanation

A. determine the amount of protein binding of the drug: Protein binding affects the drug’s activity and distribution, but peak and trough levels specifically measure blood concentration, not protein binding.

B. determine if the blood concentration is at a level to produce beneficial effects: Peak and trough levels are used to ensure the drug concentration stays within a therapeutic range—high enough to be effective but low enough to avoid toxicity. This monitoring is crucial for drugs with narrow therapeutic windows.

C. measure the distribution of the drug throughout the body: Drug distribution refers to how a drug spreads to tissues and organs, which is not directly assessed by peak and trough blood levels.

D. measure the first pass effect: The first pass effect relates to drug metabolism by the liver before reaching systemic circulation, which is not evaluated by peak and trough drug level measurements.

A. Open the airway using a jaw-thrust maneuver. B. Assess the use of accessory muscles and rate of respirations. C. Remove clothing for a thorough assessment. D. Assess blood pressure and heart rate. E. Perform a Glasgow Coma Scale assessment.

Correct Answer is A,B,D,E,C

Explanation

A. Open the airway using a jaw-thrust maneuver: The first priority in a primary survey is airway management, especially in trauma cases. The jaw-thrust technique is used to maintain cervical spine alignment while opening the airway.

B. Assess the use of accessory muscles and rate of respirations: After the airway is secured, breathing is assessed next. Observing for respiratory effort and accessory muscle use helps determine respiratory function and oxygenation needs.

D. Assess blood pressure and heart rate: The next priority is circulation, which involves checking for adequate perfusion. Vital signs like heart rate and blood pressure provide critical information about circulatory status.

E. Perform a Glasgow Coma Scale assessment: Once ABCs are stable, disability is assessed using neurological tools like the GCS to evaluate consciousness and identify any brain injury.

C. Remove clothing for a thorough assessment: Exposure is the last step in the primary survey. Clothing is removed to fully inspect for other injuries while maintaining temperature control to prevent hypothermia.

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A patient is receiving a bolus of IV fluids for dehydration. During administration of the solution, it is most important for the nurse to carefully monitor:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is to have peak and trough levels drawn for a particular drug. The nurse explains to the patient that these drug blood levels are important to:

Correct Answer is B

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Using a prioritization framework, identify the sequence of actions the nurse should take. (Arrange the boxes by dragging them in the selected order of performance.)

Correct Answer is A,B,D,E,C

Explanation

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