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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

A Foley catheter was reinserted after surgery for urinary retention is a significant factor because indwelling urinary catheters are a common source of Healthcare-Associated Infections (HAIs), specifically catheter-associated urinary tract infections (CAUTIs). The presence of a Foley catheter provides a direct pathway for bacteria to enter the bladder, increasing the risk of infection. Regular assessment of the need for the catheter and maintaining strict aseptic technique during insertion and care are essential to prevent CAUTIs. The CDC emphasizes the importance of removing catheters as soon as they are no longer necessary to reduce the risk of infection.

Choice B reason:

Retired mechanic is not directly relevant to the risk of HAIs. While Mr. Johnson’s previous occupation might provide some context about his lifestyle and potential exposure to certain risks, it does not have a direct impact on his current risk for developing HAIs. The focus should be on his current medical condition and the procedures he has undergone.

Choice C reason:

Age is a critical factor in the risk of developing HAIs. Older adults, like Mr. Johnson, have a higher risk of infections due to age-related changes in the immune system, comorbidities, and decreased physiological reserves. Age can also affect the healing process and the body’s ability to fight off infections. Therefore, Mr. Johnson’s age is an important consideration in his risk assessment for HAIs. Older patients often require more vigilant monitoring and preventive measures to reduce the risk of infections.

Choice D reason:

History of diabetes significantly increases the risk of HAIs. Diabetes can impair the immune system, making it harder for the body to fight off infections. It also affects wound healing, increasing the risk of surgical site infections (SSIs). Patients with diabetes need careful monitoring and management to prevent complications related to infections. Proper glycemic control is crucial in reducing the risk of HAIs in diabetic patients.

Choice E reason:

Incision is a direct risk factor for surgical site infections (SSIs). The midline incision from Mr. Johnson’s abdominal surgery is a potential entry point for bacteria, which can lead to infection. Proper wound care, including keeping the incision clean and dry, monitoring for signs of infection, and timely dressing changes, is crucial to prevent SSIs. Surgical site infections are among the most common HAIs and require diligent preventive measures.

Choice F reason:

Gender is not a primary factor in the risk of HAIs. While some studies suggest that certain infections may have different prevalence rates between genders, it is not a significant factor compared to the other considerations such as the presence of a catheter, age, diabetes, and surgical incision. The focus should be on the more direct risk factors that have a substantial impact on the likelihood of developing HAIs.

A. True B. False

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Choose:

Correct Answer is ["A","C","D","E"]

Explanation

Urinary tract infections are the most common healthcare-associated infection.

Correct Answer is A

Explanation

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