A nurse is caring for a client who has developed Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) from cancer. Which of the following nursing interventions should be included in the client's plan of care? (Select all that apply.)
Give the client a low sodium diet.
Monitor for serum electrolyte imbalances.
Obtain daily weights.
Educate the client on techniques to cope with thirst.
Increase IV fluids.
Correct Answer : A,B,C,D
A. Give the client a low sodium diet: SIADH causes retention of water and dilutional hyponatremia. Therefore, restricting sodium intake can help prevent further fluid retention and worsening of hyponatremia.
B. Monitor for serum electrolyte imbalances: SIADH can lead to electrolyte imbalances, particularly hyponatremia. Monitoring electrolyte levels, especially sodium, is essential for early detection and intervention.
C. Obtain daily weights: Monitoring daily weights is crucial for assessing fluid balance and detecting changes in hydration status, which is essential in clients with SIADH.
D. Educate the client on techniques to cope with thirst: Clients with SIADH often experience excessive thirst due to the body's inability to excrete excess water. Educating the client on strategies to manage thirst, such as chewing gum or sucking on ice chips, can help improve comfort.
E. Increase IV fluids: This option is incorrect because SIADH is characterized by water retention, so increasing IV fluids would exacerbate the condition and worsen hyponatremia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Sterilize dishes before using: This is not typically necessary. Washing dishes with hot water and soap or using a dishwasher is sufficient to ensure they are clean.
B. Maintain good hygiene: Good hygiene practices are crucial for immunocompromised individuals to prevent infections.
C. Cook meats and fish well: Properly cooking meats and fish helps to kill any harmful bacteria and parasites that could cause infections.
D. Avoid consuming raw foods: Raw foods, especially meats, eggs, and some vegetables, can harbor harmful bacteria and parasites, posing a risk of infection.
E. Wash hands frequently: Frequent handwashing is one of the most effective ways to prevent the spread of infections.
Correct Answer is B
Explanation
A. Document how many inches the tube has been inserted: While documentation of the tube insertion depth is important, it is not the highest priority immediately after intubation. Ensuring proper placement and ventilation take precedence.
B. Auscultate both lungs for the presence of breath sounds: This is the priority action to confirm that the endotracheal tube is correctly placed in the trachea and that both lungs are being ventilated adequately. Absence of breath sounds on one side could indicate mainstem intubation or displacement of the tube.
C. Secure the endotracheal tube to prevent dislodgement: Securing the tube is important, but it should be done after confirming proper placement and ventilation.
D. Obtain a chest x-ray to ensure correct tube placement: While a chest x-ray is often performed after intubation to confirm tube placement, it is not the immediate priority. Auscultation provides more immediate feedback on the effectiveness of ventilation.
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