A 49-year-old female patient receives 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Peripheral pulses
Urinary output
Peripheral edema
Lung sounds and neurological status
The Correct Answer is D
Choice A: Peripheral pulses
Monitoring peripheral pulses is important for assessing circulation and detecting any signs of vascular complications. However, it is not the most critical assessment for a patient receiving 3% NaCl for hyponatremia. The primary concern with hypertonic saline infusion is the risk of fluid overload and central nervous system (CNS) complications.
Choice B: Urinary output
Monitoring urinary output is essential for assessing kidney function and fluid balance. While it is important, it is not the most critical assessment in this scenario. The primary risks associated with 3% NaCl infusion include rapid changes in serum sodium levels and potential CNS complications.
Choice C: Peripheral edema
Peripheral edema can indicate fluid overload, but it is not the most immediate concern when administering hypertonic saline. The nurse should prioritize monitoring for signs of pulmonary edema and neurological changes, which can occur more rapidly and have more severe consequences.
Choice D: Lung sounds and neurological status
Monitoring lung sounds and neurological status is the most important assessment for a patient receiving 3% NaCl for hyponatremia. Hypertonic saline can cause rapid shifts in fluid balance, leading to pulmonary edema and neurological complications such as osmotic demyelination syndrome. Assessing lung sounds helps detect early signs of fluid overload in the lungs, while monitoring neurological status helps identify any changes in mental status or neurological function that could indicate serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: True
Urinary tract infections (UTIs) are indeed the most common type of healthcare-associated infection (HAI). According to the Centers for Disease Control and Prevention (CDC), UTIs account for more than 30% of infections reported by acute care hospitals. These infections are primarily caused by the use of catheters and other instrumentation of the urinary tract, which can introduce bacteria and lead to infection. The high prevalence of UTIs in healthcare settings underscores the importance of stringent infection control practices to prevent these infections.
Choice B: False
The statement that UTIs are not the most common healthcare-associated infection is incorrect. While other types of HAIs, such as surgical site infections, bloodstream infections, and pneumonia, are also significant, UTIs remain the most frequently reported. The use of urinary catheters is a major risk factor, and efforts to reduce catheter use and improve catheter care are critical in preventing these infections.
Correct Answer is ["B","C"]
Explanation
Choice A: Hyponatremia - Dehydration
Hyponatremia occurs when the sodium levels in the blood are abnormally low. While dehydration can contribute to hyponatremia, it is not the most common cause. Hyponatremia is more frequently caused by conditions that lead to an excess of water in the body, diluting the sodium levels. These conditions include heart failure, kidney disease, and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Choice B: Hypomagnesemia - Chronic alcoholism
This is a correct pairing. Hypomagnesemia, or low magnesium levels in the blood, is often associated with chronic alcoholism. Alcoholism can lead to poor dietary intake of magnesium, increased urinary excretion of magnesium, and gastrointestinal losses due to vomiting and diarrhea. These factors contribute to the development of hypomagnesemia in individuals with chronic alcoholism.
Choice C: Hyperkalemia - Kidney failure
This is also a correct pairing. Hyperkalemia, or high potassium levels in the blood, is commonly caused by kidney failure. The kidneys are responsible for excreting excess potassium from the body. When the kidneys are not functioning properly, they cannot remove potassium efficiently, leading to its accumulation in the blood. Other causes of hyperkalemia include certain medications, such as potassium-sparing diuretics, and conditions that cause cellular breakdown, such as rhabdomyolysis.
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