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 ["0.75"]
Explanation
Calculate the volume of the reconstituted solution that contains the prescribed dose of 0.1875 mg. Since the reconstituted solution has a concentration of 0.25 mg per 1 mL, we can set up a proportion to find the answer: (0.1875 mg / X mL) = (0.25 mg / 1 mL).
Solving for X gives us X = (0.1875 mg * 1 mL) / 0.25 mg, which equals 0.75 mL.
Therefore, the nurse should administer 0.75 mL of the reconstituted solution.
Correct Answer is D
Explanation
Rationale
A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.
B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.
C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.
D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.
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