A nurse is caring for a client who has hypomagnesemia due to chronic alcohol use disorder. Which of the following actions should the nurse take?

Choice A reason:

Monitoring neurological status is a priority intervention for a client who has overhydration and hyponatremia because these conditions can cause cerebral edema, increased intracranial pressure, and altered mental status. The nurse should assess the client for signs of confusion, lethargy, seizures, and coma, and report any changes to the provider.

Choice B reason:

Administering sodium polystyrene sulfonate is not indicated for a client who has overhydration and hyponatremia. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. It has no effect on sodium levels or fluid balance.

Choice C reason:

Providing oral hygiene frequently is a supportive intervention for a client who has overhydration and hyponatremia, but it is not a priority. Oral hygiene can help prevent dry mouth, infections, and discomfort caused by fluid retention and electrolyte imbalance. However, it does not address the underlying causes or complications of the disorder.

Choice D reason:

Restricting sodium intake as prescribed is an essential intervention for a client who has overhydration and hyponatremia. Sodium intake can affect the serum sodium level and the fluid balance in the body. Excessive sodium intake can worsen fluid retention and edema, while inadequate sodium intake can exacerbate hyponatremia. The nurse should follow the provider's orders regarding sodium restriction and educate the client on how to avoid high-sodium foods and beverages.

Choice E reason:

Encouraging foods high in protein is not appropriate for a client who has overhydration and hyponatremia. Protein intake can affect the serum osmolality and the fluid distribution in the body. High-protein foods can increase the osmotic pressure in the blood vessels, drawing more fluid from the interstitial and intracellular spaces. This can worsen overhydration and hyponatremia by diluting the serum sodium level further. The nurse should consult with a dietitian regarding the optimal protein intake for the client.

Choice A reason: Pneumothorax: This is a condition where air accumulates in the pleural space, causing the lung to collapse. It can occur during insertion of a central venous catheter if the needle or catheter punctures the lung or the pleura.

Choice B reason:. Air embolism. This is a condition where air bubbles enter the bloodstream and obstruct blood flow. It can occur during insertion, removal or maintenance of a central venous catheter if air enters the catheter or the vein.

Choice C reason:. Catheter-related bloodstream infection. This is an infection that occurs when microorganisms colonize the catheter or the insertion site and enter the bloodstream. It can cause fever, chills, sepsis and other serious complications. It can be prevented by using strict aseptic technique and following infection control guidelines.

Choice D reason:. Catheter occlusion. This is a condition where the catheter lumen becomes blocked by blood clots, fibrin sheaths, precipitates or kinks. It can impair the infusion or withdrawal of fluids and medications. It can be prevented by flushing the catheter regularly with saline or heparin solutions.

Choice E reason: Hematoma formation. This is a condition where blood accumulates under the skin or in the tissues around the insertion site. It can occur due to bleeding from the punctured vein or artery, or from trauma to the site. It can cause pain, swelling, bruising and infection.