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 A

Explanation

A. Be sure to take your potassium supplements: Furosemide is a loop diuretic that increases the excretion of sodium and water along with potassium. Hypokalemia is a common side effect, so potassium supplementation or increased dietary intake may be necessary to prevent complications such as muscle cramps or cardiac arrhythmias.

B. Report any excessive urinating to your physician: Increased urination is an expected therapeutic effect of Furosemide. It is only concerning if it leads to dehydration, dizziness, or signs of electrolyte imbalance.

C. Take your Lasix at night before bed: Taking Furosemide at night is not recommended due to its diuretic effect, which may cause nocturia and disrupt sleep. It is best taken in the morning or early afternoon.

D. Report any skin changes to your physician: Skin changes are not a common or critical concern specifically associated with Furosemide. Monitoring for electrolyte imbalances and dehydration is more important in routine patient education.

A. The charge nurse B. The nursing assistant C. The nurse D. The client

Correct Answer is C

Explanation

A. The charge nurse: While the charge nurse may assist in overseeing patient care, the responsibility for reporting changes in a specific patient's condition lies with the nurse assigned to that patient. Delegation does not remove the accountability of the primary nurse.

B. The nursing assistant: Nursing assistants are not licensed to interpret or report critical changes in a patient's condition. They may measure vital signs but must report abnormal findings to the licensed nurse, who is responsible for further action.

C. The nurse: The nurse caring for the client is ultimately responsible for assessing the situation, interpreting the data, and notifying the healthcare provider. Timely communication of significant changes in condition is a key nursing responsibility.

D. The client: Although the client may express concern about symptoms, it is not their responsibility to report changes to the provider. It is the nurse’s duty to act on clinical findings and initiate communication with the medical team.

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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 nurse is performing discharge teaching with her patient and going over the information about her Furosemide (Lasix) (loop diuretic). One important teaching point for the nurse to remember is:

Correct Answer is A

Explanation

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the health care provider?

Correct Answer is C

Explanation

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