A client is receiving 3% of saline continues IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
There are crackles audible throughout bilateral lung fields.
The blood pressure increases from 120/80- to 142/94
There is slight sediment and blood in the client’s urine.
The client’s radial pulse is 105 beats/minute.
The Correct Answer is A
A. There are crackles audible throughout bilateral lung fields: The presence of crackles in both lungs indicates fluid overload and pulmonary edema, a life-threatening complication of hypertonic saline infusion. Rapid intervention, including slowing or stopping the infusion and notifying the healthcare provider, is necessary to prevent respiratory compromise.
B. The blood pressure increases from 120/80 to 142/94: A moderate rise in blood pressure may indicate increased intravascular volume from the hypertonic saline, but it is not immediately life-threatening. It requires monitoring but is less urgent than pulmonary edema.
C. There is slight sediment and blood in the client’s urine: Minor hematuria or sediment may indicate irritation or a pre-existing condition but does not require immediate action in the context of rapid sodium correction. Monitoring and follow-up are appropriate.
D. The client’s radial pulse is 105 beats/minute: Mild tachycardia can result from hypertonic fluid infusion or mild stress. While it warrants monitoring, it is not as urgent as the development of pulmonary edema, which can rapidly compromise oxygenation and perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Client who is experiencing hallucinations and extreme anxiety after the use of marijuana: Hallucinations and anxiety are distressing but generally not life-threatening effects of marijuana use. These symptoms can be managed with reassurance and a calm environment once physical safety is ensured.
B. Client with a history of alcohol use complaining of insomnia and diaphoresis: These symptoms suggest early alcohol withdrawal, which can progress to serious complications like seizures or delirium tremens if untreated. However, at this stage, the client's symptoms are mild and not immediately life-threatening.
C. Client who has a respiration rate of 14 after overdosing on oxycodone (OxyContin): Although opioid overdose can cause respiratory depression, a rate of 14 indicates adequate ventilation for now. The client should still be closely monitored, but there is no immediate evidence of respiratory failure.
D. Client admitted with cocaine use who has an irregular heart rate of 142 beats/minute and a BP 186/92 mmHg: Cocaine toxicity can trigger severe cardiovascular complications. The markedly elevated heart rate and BP indicate acute sympathetic overactivity, which requires rapid stabilization and cardiac monitoring to prevent life-threatening outcomes.
Correct Answer is D
Explanation
A. Bladder irrigation decreases the risk of postoperative bleeding: Continuous bladder irrigation does not directly prevent bleeding. Its primary purpose is not hemostasis, although it may help flush small clots. Bleeding is managed with surgical technique, medications, or monitoring, not the irrigation itself.
B. Hydration and urine output are maintained by bladder irrigation: Irrigation does not provide systemic hydration or replace fluid lost. It only flushes the bladder lumen and does not contribute significantly to the client’s overall fluid balance or urine production.
C. Antibiotics are infused continuously through the bladder irrigation: Continuous bladder irrigation is not a route for antibiotic administration. Antibiotics are given systemically (IV or oral) to prevent or treat infection, not through the irrigation solution.
D. Bladder irrigation prevents obstruction of the catheter after surgery: The primary purpose of continuous bladder irrigation after TURP is to prevent catheter blockage from blood clots and tissue debris. Maintaining catheter patency ensures urine drainage, reduces bladder distention, and decreases the risk of postoperative complications.
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