The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate?
Fluid volume deficit
Fluid volume excess
Speed shock
Pulmonary embolism
The Correct Answer is B
Choice A reason: Fluid volume deficit is a condition in which the body loses more fluid than it gains, resulting in dehydration, hypotension, and electrolyte imbalances. It is not a complication of IV fluid therapy, but rather a reason for initiating it.
Choice B reason: Fluid volume excess is a condition in which the body retains more fluid than it needs, resulting in edema, hypertension, and heart failure. It is a potential complication of IV fluid therapy, especially in older adults who have reduced renal function and cardiac output. The nurse's assessment findings of crackles, shortness of breath, and jugular vein distention are indicative of fluid overload and pulmonary congestion.
Choice C reason: Speed shock is a systemic reaction that occurs when a substance is administered too rapidly into the bloodstream, causing adverse effects such as chest pain, dyspnea, hypotension, and cardiac arrest. It is not a complication of IV fluid therapy, but rather a risk associated with IV medication administration.
Choice D reason: Pulmonary embolism is a blockage of one or more pulmonary arteries by a blood clot, fat, or air, causing impaired gas exchange, chest pain, dyspnea, and hemoptysis. It is not a complication of IV fluid therapy, but rather a possible outcome of venous thromboembolism, which can be prevented by using anticoagulants and mechanical devices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: William, who exercises three times a week, does not have a modifiable risk factor for osteoporosis. Exercise is actually beneficial for bone health, as it stimulates bone formation and reduces bone loss. Exercise also improves muscle strength, balance, and coordination, which can prevent falls and fractures.
Choice B reason: Samantha, who has a family history of osteoporosis, does not have a modifiable risk factor for osteoporosis. Family history is a genetic factor that cannot be changed or controlled. Having a parent or sibling with osteoporosis increases the risk of developing the condition, especially if they have had a fracture.
Choice C reason: Juanita, who smokes two packs of cigarettes a day, has a modifiable risk factor for osteoporosis. Smoking is a lifestyle factor that can be changed or controlled. Smoking increases the risk of osteoporosis by reducing the blood supply to the bones, decreasing the absorption of calcium, and lowering the levels of estrogen, which protects the bones.
Choice D reason: Tori, who is postmenopausal at age 40, does not have a modifiable risk factor for osteoporosis. Menopause is a natural process that occurs when the ovaries stop producing estrogen, which leads to bone loss and increased risk of fractures. Menopause cannot be prevented or reversed, but its effects on bone health can be managed with hormone therapy, calcium, and vitamin D supplements.
Correct Answer is D
Explanation
Choice A reason: Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.
Choice B reason: Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.
Choice C reason: Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.
Choice D reason: Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.
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