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A nurse is caring for afemale client in an outpatient clinic.

Exhibits
Click to highlight the findings that require immediate follow-up. Tо deselect a finding, click on the finding again.

Nurses' Notes

Day 1:

Client is seen by provider for routine follow-up after being started on oxcarbazepine 150mg PO twice a day, last week. Client reports no nausea, headache, dizziness, or ataxia. Provider increased oxcarbazepine to 300 mg PO twice a day. Client is to return for a follow-up in 2 weeks.

Day 14:

Client returns for follow-up after increasing oxcarbazepine dosage. Client reports starting to have mild headaches earlier this week. Also states, "Yesterday I was very nauseated and threw up before breakfast." When talking to client they have difficulty remembering the times they are taking their oxcarbazepine. Client reports using oral contraceptives as the only means of birth control.

Laboratory Results

Day 14:

Hct 40% (37% to 47%)

Hgb 13g/dL (12 to 16g/dL)

Sodium 124 mEq/L (136 to 145 mEq/L)

Vitals Signs

Day 14:

Temperature 36.3° C (97.4° F)

Heart rate 86/min

Blood pressure 110/66 mm Hg

Respiratory rate 16/min

Client reports starting to have mild headaches earlier this week.

Also states, "Yesterday I was very nauseated and threw up before breakfast."

When talking to client they have difficulty remembering the times they are taking their oxcarbazepine.

Client reports using oral contraceptives as the only means of birth control.

Hct 40% (37% to 47%)

Hgb 13g/dL (12 to 16g/dL)

Sodium 124 mEq/L (136 to 145 mEq/L)

Temperature 36.3° C (97.4° F)

Heart rate 86/min

Blood pressure 110/66 mm Hg

Answer and Explanation

The Correct Answer is ["B","C","G"]

Rationale for correct choices:

Sodium 124 mEq/L: The client’s serum sodium is critically low, indicating severe hyponatremia, a known serious adverse effect of oxcarbazepine. Hyponatremia can lead to confusion, seizures, and potentially life-threatening neurological complications, requiring immediate provider follow-up and possible medication adjustment or discontinuation.
Difficulty remembering medication times: Cognitive changes or confusion may indicate central nervous system effects of oxcarbazepine or complications from hyponatremia. This finding signals the need for urgent reassessment and intervention to prevent medication errors or toxicity.
Nausea/vomiting: Persistent nausea and vomiting, especially after a recent dose increase, may be a sign of drug intolerance, early hyponatremia symptoms, or central nervous system effects. Immediate follow-up is necessary to prevent further complications and dehydration.

Rationale for Incorrect Choices:

Mild headache: While headaches may occur with oxcarbazepine, the mild nature and recent onset are less urgent compared with severe hyponatremia and neurological symptoms.
Vital signs (HR 86, BP 110/66, Temp 36.3° C, RR 16): These are slightly lower than baseline but not immediately concerning. The priority is lab abnormality and neurological changes.
Hct 40%, Hgb 13 g/dL: These values remain within normal limits and do not require immediate intervention.
Use of oral contraceptives: This is important for counseling because oxcarbazepine can reduce contraceptive efficacy, but it is not an urgent clinical finding compared to hyponatremia.

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Free Nursing Study Resources

Correct Answer is ["B","C","G"]

Explanation

Rationale for correct choices:

Sodium 124 mEq/L: The client’s serum sodium is critically low, indicating severe hyponatremia, a known serious adverse effect of oxcarbazepine. Hyponatremia can lead to confusion, seizures, and potentially life-threatening neurological complications, requiring immediate provider follow-up and possible medication adjustment or discontinuation.
Difficulty remembering medication times: Cognitive changes or confusion may indicate central nervous system effects of oxcarbazepine or complications from hyponatremia. This finding signals the need for urgent reassessment and intervention to prevent medication errors or toxicity.
Nausea/vomiting: Persistent nausea and vomiting, especially after a recent dose increase, may be a sign of drug intolerance, early hyponatremia symptoms, or central nervous system effects. Immediate follow-up is necessary to prevent further complications and dehydration.

Rationale for Incorrect Choices:

Mild headache: While headaches may occur with oxcarbazepine, the mild nature and recent onset are less urgent compared with severe hyponatremia and neurological symptoms.
Vital signs (HR 86, BP 110/66, Temp 36.3° C, RR 16): These are slightly lower than baseline but not immediately concerning. The priority is lab abnormality and neurological changes.
Hct 40%, Hgb 13 g/dL: These values remain within normal limits and do not require immediate intervention.
Use of oral contraceptives: This is important for counseling because oxcarbazepine can reduce contraceptive efficacy, but it is not an urgent clinical finding compared to hyponatremia.

A. Obtain a prescription for furosemide. B. Prepare the client for a urine culture and sensitivity. C. Discontinue the potassium infusion. D. Perform a bladder scan.

Correct Answer is C

Explanation

A. Obtain a prescription for furosemide: Administering a diuretic like furosemide could worsen hypovolemia or kidney injury if the client is already oliguric. It is not the first action when potassium is accumulating due to impaired renal excretion.

B. Prepare the client for a urine culture and sensitivity: While a UTI could contribute to kidney dysfunction, the immediate concern is elevated potassium in the context of severely reduced urine output, making infection screening secondary.

C. Discontinue the potassium infusion: The client has oliguria and elevated BUN, indicating impaired renal function. Continuing potassium infusion could lead to hyperkalemia and life-threatening cardiac complications. Stopping the infusion is the priority action to prevent toxicity.

D. Perform a bladder scan: A bladder scan assesses for urinary retention, which could contribute to low urine output. However, the elevated BUN suggests intrinsic kidney impairment, making discontinuing potassium more urgent than assessing retention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","G"]

Explanation

A nurse is caring for a client who is receiving an intravenous potassium infusion and who has a urine output of 10 mL/hr and a blood urea nitrogen of 50 mg/dL (10 to 20 mg/dL). Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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