An older client receiving intravenous fluids at 175 ml/hr is ...

[WWatsford]

An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy?
 
  1. An allergic reaction to the antibiotics in the fluid
  2. Fluid volume excess
  3. Pulmonary embolism
  4. Speed shock

Question 2

The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take?
 
  1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema.
  2. Measure the client's heart rate and blood pressure in both the sitting and standing position.
  3. Measure the client's blood pressure before, during, and after administration of a normal saline fluid challenge.
  4. Raise the client's legs above heart level and measure the blood pressure.

[ryhom]

Answer to Question 1

Correct Answer: 2
Rationale 1: The information provided does not support that the client is receiving an antibiotic.
Rationale 2: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly.
Rationale 3: The information provided does not support the development of a pulmonary embolism.
Rationale 4: The client has been receiving fluids at the established rate and would not be experiencing symptoms of speed shock.

Answer to Question 2

Correct Answer: 2
Rationale 1: Assessment of edema is not a part of the assessment of orthostatic hypotension.
Rationale 2: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position.
Rationale 3: Normal saline challenges are often administered to clients who are dehydrated, but they are not part of assessment of orthostatic hypotension.
Rationale 4: The nurse should measure the client's blood pressure and heart rate in the sitting position and then again in the standing position.