An older client is receiving an IV of 0.9% Normal Saline solution at 75 mL/hour. Which finding indicates to the practical nurse that the client may be developing a complication from this therapy?
Episodes of vertigo and loss of balance.
Fatigue and breathlessness upon exertion.
Apical pulse rate of 64 beats/minute.
Average 24-hour urinary output of 1,400 mL.
The Correct Answer is B
A. Episodes of vertigo and loss of balance: These findings are more commonly associated with vestibular or neurological disorders rather than IV fluid complications. They do not directly indicate fluid overload or electrolyte imbalance from normal saline infusion.
B. Fatigue and breathlessness upon exertion: These symptoms suggest fluid volume excess, which can occur when IV fluids accumulate faster than the body can handle. Older adults are especially prone to heart failure and pulmonary congestion, leading to dyspnea and generalized fatigue from decreased oxygen exchange.
C. Apical pulse rate of 64 beats/minute: A pulse rate within this range is normal for many adults and does not indicate fluid imbalance or overload. It reflects a stable cardiovascular status rather than a complication of IV therapy.
D. Average 24-hour urinary output of 1,400 mL: This urinary output is within normal limits for an adult (about 30 mL/hour minimum). It indicates adequate renal function and does not signal fluid overload or retention related to IV therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. Transport a urine culture sample to the laboratory: Transporting specimens is within the UAP’s scope of practice. It involves safe handling and timely delivery but does not require clinical judgment or assessment skills, making it appropriate to delegate.
B. Empty bedside drainage unit for a client with indwelling urinary catheter: UAPs are trained to empty catheter drainage bags and record output. This task is routine, does not involve sterile technique beyond standard precautions, and falls within their competency.
C. Teach the client with fluid restrictions how to measure urine output: Teaching requires assessment, explanation, and evaluation of client understanding, which are nursing responsibilities. The UAP cannot independently provide education or evaluate comprehension.
D. Irrigate an indwelling urinary catheter for a client with bladder suspension: Catheter irrigation is a sterile, invasive procedure requiring clinical judgment and monitoring for complications. This task must be performed by licensed nursing personnel, not a UAP.
E. Obtain a post-voided residual (PVR) volume: Measuring PVR often involves using a bladder scanner and interpreting results, requiring assessment skills and clinical decision-making. This is outside the UAP’s scope and must be performed by a licensed nurse.
Correct Answer is A
Explanation
A. Provide gentle and meticulous mouth care: Stomatitis causes painful inflammation and ulceration of the oral mucosa. Gentle, thorough oral care reduces the risk of infection, promotes healing, and helps maintain oral hygiene, making this the most important instruction for the UAP.
B. Keep the room environment free of unpleasant odors: Minimizing odors can help with nausea, but it does not directly address stomatitis care. This is a supportive measure, not a primary intervention.
C. Assist the client with feeding at meal times: Assistance with feeding is helpful for comfort and nutrition, but it does not directly manage the oral lesions or reduce infection risk.
D. Gather supplies for protective environment precautions: Protective environment precautions are primarily used for clients with severe immunosuppression. While important in some chemotherapy settings, the key intervention for stomatitis is proper oral care.
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