A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids?
The client has developed confusion.
The client's serum sodium is 140 mEq/L (135 to 145 mEq/L).
The client has a positive Chvostek's sign.
The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL).
The Correct Answer is A
A. The client has developed confusion: Hypotonic fluids can cause a rapid shift of water into cells, potentially leading to cerebral edema. This can manifest as confusion or altered mental status, which is a serious adverse effect requiring immediate attention.
B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L): A serum sodium level within the normal range indicates that the hypotonic fluid therapy is likely effective in correcting hypernatremia, and does not suggest an adverse effect.
C. The client has a positive Chvostek's sign: A positive Chvostek's sign is indicative of hypocalcemia rather than an adverse effect of hypotonic fluid administration. This sign is related to low calcium levels and is not a direct result of hypotonic fluid therapy.
D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL): This BUN level is within normal limits and does not suggest an adverse effect of hypotonic fluid therapy. BUN levels can be affected by various factors, but this value alone is not indicative of an adverse reaction.
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Related Questions
Correct Answer is D
Explanation
A. Respiratory alkalosis: This condition is characterized by a high pH and low PaCO2. In this case, the pH is low and PaCO2 is high, indicating that respiratory alkalosis is not present.
B. Metabolic acidosis: Metabolic acidosis is indicated by a low pH and a low bicarbonate level. Here, the pH is low but the bicarbonate level is normal, so metabolic acidosis is not the primary diagnosis.
C. Metabolic alkalosis: This condition involves a high pH and elevated bicarbonate. The pH in this case is low, so metabolic alkalosis is not present.
D. Respiratory acidosis: Respiratory acidosis is indicated by a low pH and high PaCO2. The client's pH is 7.22 (acidic) and PaCO2 is 68 mm Hg (elevated), which is consistent with respiratory acidosis. The bicarbonate level is normal, indicating that there is no significant metabolic compensation yet.
Correct Answer is A
Explanation
A. Expiratory wheeze: Wheezing, particularly on expiration, is a characteristic finding during an acute asthma exacerbation. It occurs due to the narrowing of the airways and turbulent airflow.
B. Rhonchi: Rhonchi are low-pitched, rattling sounds often caused by secretions in larger airways, not typically associated with asthma exacerbations.
C. Pleural friction rub: A pleural friction rub is a grating sound heard when the pleurae are inflamed, often seen in conditions like pleuritis, not asthma.
D. Fine rales: Fine rales, or crackles, are associated with fluid in the alveoli, often found in conditions like pneumonia or heart failure, rather than asthma
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