A client has been diagnosed with hyponatremia and is confused. Which intervention does the nurse include in the client’s plan of care to relieve the confusion?
Placing the patient in Trendelenburg position
Measuring intake and output every shift.
Increase the lactated ringer IV flow rate to 100 mL/hr.
Administering mannitol as prescribed by the physician
The Correct Answer is B
A. Placing the patient in Trendelenburg position: Trendelenburg position does not correct hyponatremia or relieve confusion. It is primarily used to manage hypotension and would not address the neurological symptoms caused by low sodium.
B. Measuring intake and output every shift: Monitoring fluid balance helps prevent further dilutional hyponatremia and allows the healthcare team to manage fluid restrictions or replacements appropriately. Accurate I&O tracking is essential for preventing worsening confusion related to electrolyte imbalance.
C. Increase the lactated ringer IV flow rate to 100 mL/hr: Increasing isotonic fluid without provider orders may worsen hyponatremia or fluid overload. Fluid therapy must be carefully managed based on serum sodium levels and clinical status.
D. Administering mannitol as prescribed by the physician: Mannitol is an osmotic diuretic used to reduce intracranial pressure, not to correct hyponatremia. It would not directly relieve confusion caused by low sodium levels and could complicate fluid and electrolyte balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. It blocks the release of luteinizing hormone: Tamoxifen does not act on the pituitary gland to block luteinizing hormone. This mechanism is unrelated to its role in breast cancer prevention.
B. It interferes with cancer cell division: While tamoxifen affects cancer growth, its primary action is not directly interfering with cell division like traditional cytotoxic chemotherapy.
C. It selectively blocks estrogen in the breast: Tamoxifen is a selective estrogen receptor modulator (SERM) that binds to estrogen receptors in breast tissue, blocking estrogen’s proliferative effect on breast cells. This action helps lower the risk of estrogen receptor-positive breast cancer.
D. It inhibits DNA synthesis in rapidly dividing cells: Inhibiting DNA synthesis describes the mechanism of cytotoxic chemotherapy, not tamoxifen. Tamoxifen’s effect is receptor-mediated rather than directly cytotoxic.
Correct Answer is A
Explanation
A. Ask the client about preferred forms of address: The safest and most respectful approach is to ask the client how they prefer to be addressed. This acknowledges the possibility of a name discrepancy, respects the client’s identity, and avoids assumptions based on appearance or chart information.
B. Explain that the chart must contain an error: Assuming the chart is wrong may embarrass the client or create mistrust. The chart could be accurate but reflect a preferred name, legal name, or gender identity that differs from appearance.
C. Apologize and declare confusion about the client: Expressing personal confusion can make the client uncomfortable and does not resolve the situation professionally. It may undermine the client’s confidence in the nurse’s competence.
D. Ask Mrs. Smith where her husband is right now: Making assumptions about marital status or gender based on chart name is inappropriate and irrelevant to the client’s care. This approach risks offense and does not clarify identity or preferred address.
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