A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement?Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
Assess for increasing fluid volume overload.
Withhold next scheduled dose of treatment.
Increase neurologic checks to every 2 hours.
Maintain the prescribed fluid restriction.
The Correct Answer is D
A. Assessing for increasing fluid volume overload is not indicated with a rising serum sodium level; instead, it suggests correction of hyponatremia, a common complication of SIADH.
B. Withholding the next scheduled dose of treatment is not appropriate based solely on a rise in serum sodium level within the normal range.
C. Increasing neurologic checks may be necessary in severe cases of hyponatremia but is not directly indicated by a rise in serum sodium within the normal range.
D. Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.
B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.
C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.
D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.
Correct Answer is D
Explanation
A. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.
B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.
C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.
D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.
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