A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?
Measure ankle circumference.
Obtain serum creatinine levels daily.
Ensure client takes a diuretic every morning.
Monitor daily sodium intake.
The Correct Answer is C
Rationale
A. This intervention is important for assessing peripheral edema, which can indicate fluid overload. While relevant, it is not the highest priority in addressing acute weight gain and elevated blood pressure.
B. Daily monitoring of serum creatinine is important but is more relevant once diuretic therapy is initiated to assess renal function and electrolyte balance.
C. This option is crucial because diuretic therapy is aimed at correcting fluid imbalance in SIADH. However, the timing and dosage of diuretics should be adjusted based on clinical assessment and not solely on a fixed morning administration.
D. Monitoring sodium intake is a long-term strategy in managing SIADH to prevent hyponatremia. While important, it does not address the immediate concerns of fluid overload and elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12.5"]
Explanation
To calculate the dosage of amoxicillin suspension to be administered every 8 hours, one must first determine the total daily dosage in milligrams. Since 1 gram equals 1000 milligrams, 1.5 grams is equivalent to 1500 milligrams. This total daily dosage needs to be divided into three doses, as it will be administered every 8 hours.
Therefore, each dose will be 1500 mg divided by 3, which equals 500 mg per dose. The medication bottle states that there are 200 mg of amoxicillin in every 5 mL of suspension. To find out how many mL correspond to a 500 mg dose, set up a proportion: 200 mg/5 mL = 500 mg/x mL. Solving for x gives x = (500 mg * 5 mL) / 200 mg, which equals 12.5 mL
Therefore, the nurse should administer 12.5 mL of the amoxicillin suspension every 8 hours.
Correct Answer is B
Explanation
Rationale
A. This action is important to prevent unauthorized access to medications by the client or other patients. However, this is not the priority
B. Soft drink cans can potentially be used to harm oneself or others (e.g., by smashing or as a cutting tool). Removing these items helps to reduce the risk of self-injury or harm to others.
C. This action is typically done to safely dispose of any items that may be considered biohazardous, such as used tissues, bandages, or any items contaminated with bodily fluids. It helps to maintain infection control and prevent exposure to potentially infectious materials.
D. In some mental health units, clients may not be allowed to have personal electronic devices due to concerns about confidentiality, safety, or potential disruption. Providing a unit-controlled telephone allows staff to monitor communication and ensure it is appropriate and supportive
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