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 ["18"]
Explanation
(Desired Dose * Volume of IV Bag) / (Concentration of Drug in IV Bag * Time) = Infusion Rate.
For the given prescription, the calculation would be: (900 units/hr * 500 mL) / (25,000 units) = 18 mL/hr.
Therefore, the nurse should program the infusion pump to deliver 18 mL/hr.
Correct Answer is ["A","B","C","D"]
Explanation
Apply a body shrouding is appropriate as it covers the body, maintaining privacy and dignity. It's a common practice to cover the body with a sheet or shroud to ensure modesty.
B. Removing resuscitation equipment from the room is important to remove any reminders of medical interventions and procedures, allowing the family to focus on saying goodbye to their loved one without the presence of medical equipment that may be distressing.
C. Closing the eyes of the deceased is a respectful gesture in many cultures. It can create a peaceful appearance and is often considered a final act of care.
D. Place a small pillow under the head to support the head and neck in a more natural position. It helps create a more relaxed and comfortable appearance for the deceased.
E. Removing dentures is not typically done immediately after death, as it can alter the deceased's facial appearance.
NGNS
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