A client with cirrhosis presents with a serum sodium level of 127 mEq/L. Which of the following interventions should the nurse prioritize in the client's care plan after discussion with the provider?

Increase fluid intake to help elevate sodium levels.

Monitor albumin levels for nutritional status evaluation.

Encourage foods high in potassium to balance electrolytes.

Hold diuretics to prevent further electrolyte imbalance.

Answer and Explanation

The Correct Answer is D

Cirrhosis is a chronic liver disease characterized by impaired hepatic function, portal hypertension, and fluid and electrolyte disturbances. One common complication is dilutional hyponatremia, where serum sodium levels decrease due to fluid retention and altered renal handling of water. Management focuses on correcting fluid imbalance while avoiding interventions that further worsen sodium depletion. Diuretics, often used for ascites, can contribute to electrolyte imbalances and may need adjustment in severe hyponatremia.

Rationale:
A. Increasing fluid intake to help elevate sodium levels is inappropriate because hyponatremia in cirrhosis is usually dilutional rather than due to sodium deficiency. Additional fluid intake can further dilute serum sodium and worsen hyponatremia. Fluid restriction, not increased intake, is often considered in these cases.

B. Monitoring albumin levels for nutritional status evaluation is important in cirrhosis but is not the priority intervention for correcting acute hyponatremia. Low albumin reflects impaired liver synthetic function and contributes to fluid shifts, but it does not directly address the immediate electrolyte imbalance. Sodium correction takes precedence in this scenario.

C. Encouraging foods high in potassium to balance electrolytes is not appropriate because potassium intake does not correct hyponatremia and may worsen electrolyte imbalance. Cirrhotic clients are already at risk for multiple electrolyte disturbances, and potassium supplementation should only be guided by laboratory values. This intervention does not address the underlying sodium imbalance.

D. Holding diuretics is the priority intervention because medications such as spironolactone or furosemide can contribute to further sodium loss and fluid shifts. In the setting of a serum sodium level of 127 mEq/L, continued diuretic use may worsen hyponatremia and increase the risk of complications such as confusion, seizures, or worsening ascites management imbalance. Medication adjustment must be coordinated with the provider to stabilize sodium levels safely.

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Correct Answer is ["A","B","D"]

Explanation

Ischemic stroke occurs when blood flow to a portion of the brain is obstructed, leading to cerebral ischemia and potential infarction. Rapid assessment and intervention are critical to preserve brain tissue and reduce long-term neurological deficits. Management priorities include stabilizing physiological parameters, identifying eligibility for thrombolytic therapy, and closely monitoring for complications such as hemorrhage or worsening neurological status. Time-sensitive treatment significantly influences patient outcomes.

Rationale:
A. Ensuring continuous assessment of blood pressure and glucose levels is essential because both hypertension and hypoglycemia or hyperglycemia can worsen cerebral injury. Blood pressure must be carefully managed to maintain adequate cerebral perfusion without increasing the risk of hemorrhagic transformation. Glucose levels also affect neuronal recovery and should be tightly controlled during the acute phase of stroke.

B. Monitoring for signs of bleeding and neurological status following thrombolytic therapy is critical because thrombolytics significantly increase the risk of intracranial and systemic hemorrhage. Frequent neurological assessments help detect early deterioration, while monitoring for bleeding ensures timely intervention. This is especially important after administration of fibrinolytic agents.

C. Initiating a comprehensive rehabilitation plan before stabilizing the client's acute condition is not appropriate. Acute management must first focus on stabilizing the client, ensuring airway protection, and restoring cerebral perfusion. Rehabilitation is an important part of recovery but should begin only after the client is medically stable.

D. Administering intravenous alteplase within the appropriate time frame if not contraindicated is a priority intervention for eligible clients with ischemic stroke. Alteplase works by dissolving the thrombus and restoring cerebral blood flow. Timely administration within the therapeutic window is critical to minimize brain damage and improve functional outcomes.

E. Educating the client on the importance of balancing nutritional intake without focusing on specific dietary restrictions is not an acute priority. While nutrition education is important for long-term stroke prevention, immediate management focuses on stabilizing neurological function and preventing complications. Specific dietary modifications are addressed later in the recovery phase.

A. Fever and fluid retention B. A steady increase in urine output C. Decreased blood creatinine levels D. Increased appetite and weight gain

Correct Answer is A

Explanation

After a kidney transplant, the immune system may recognize the transplanted organ as foreign and initiate an inflammatory response known as acute rejection. This typically occurs within days to months post-transplant and can compromise graft function if not identified early. Clinical monitoring focuses on early signs of inflammation, reduced renal function, and systemic changes indicating immune activation. Prompt recognition is essential to preserve graft viability and prevent irreversible damage.

Rationale:
A. Fever and fluid retention are key indicators of potential acute rejection. Fever reflects an inflammatory or immune response against the transplanted kidney. Fluid retention occurs due to impaired renal function as the rejecting kidney loses its ability to regulate fluid balance effectively, often leading to edema and hypertension.

B. A steady increase in urine output is not typically associated with acute rejection and may instead indicate improving graft function or appropriate response to therapy. In acute rejection, urine output more commonly decreases due to declining renal function and reduced glomerular filtration.

C. Decreased blood creatinine levels suggest improved kidney function rather than rejection. In acute rejection, serum creatinine typically rises due to impaired filtration and declining graft performance. A downward trend in creatinine is a reassuring finding, not a warning sign.

D. Increased appetite and weight gain are not specific indicators of acute transplant rejection. While weight gain may occur due to fluid retention, increased appetite alone is not associated with immune-mediated graft dysfunction. More specific signs such as fever, rising creatinine, and reduced urine output are more clinically relevant.

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A client with cirrhosis presents with a serum sodium level of 127 mEq/L. Which of the following interventions should the nurse prioritize in the client's care plan after discussion with the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In managing a client experiencing an ischemic stroke, which of the following interventions should be prioritized based on the client's presentation and treatment plan? Select three that apply.

Correct Answer is ["A","B","D"]

Explanation

When monitoring a client after a kidney transplant, which of the following findings would indicate a potential acute rejection of the transplant?

Correct Answer is A

Explanation

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