A nurse is caring for an endurance athlete admitted for altered mental status. The client drank large amounts of water during a recent long-distance running event. The client is confused, complaining of a headache, and has a full bounding pulse. The nurse develops the plan of care based on the expectation that the client's lab work will demonstrate which of the following abnormalities?
Serum potassium 5.0 mEq/L
Serum osmolality 294 mmol/kg
Serum sodium of 127 mEq/L
Serum hemoglobin 15.7 grams/dL
The Correct Answer is C
A. Serum potassium 5.0 mEq/L: This is within the normal range for serum potassium (3.5-5.0 mEq/L). While potassium levels are important, they are not the primary concern with symptoms of confusion and a bounding pulse due to excessive water intake.
B. Serum osmolality 294 mmol/kg: This value is within the normal range for serum osmolality (275-295 mmol/kg). Elevated or normal osmolality would not be expected in a case of water intoxication, which dilutes serum electrolytes.
C. Serum sodium of 127 mEq/L: A serum sodium level of 127 mEq/L indicates hyponatremia, a condition often caused by excessive water intake that dilutes the sodium in the bloodstream. Symptoms such as confusion, headache, and a full bounding pulse are consistent with hyponatremia, making this the expected abnormality.
D. Serum hemoglobin 15.7 grams/dL: This is within the normal range for hemoglobin (12-16 grams/dL for women and 13.8-17.2 grams/dL for men). Hemoglobin levels would not be expected to change significantly due to water intoxication.
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Related Questions
Correct Answer is D
Explanation
A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention
Correct Answer is ["A","C","D"]
Explanation
A. Monitor intake and output every shift: Important for tracking fluid balance and ensuring appropriate hydration and nutritional support.
B. Change the IV tubing every seven (7) days: IV tubing should generally be changed every 24 to 72 hours or as per hospital protocol, not every seven days.
C. Place the solution on an IV pump at the prescribed rate: Ensures accurate administration of TPN and prevents complications associated with over or under-infusion.
D. Monitor blood glucose every one (1) hour: Frequent monitoring is required as TPN can cause fluctuations in blood glucose levels.
E. Weigh the client weekly, first thing in the morning: While weighing the client is important, it is typically done more frequently than weekly to monitor fluid status and nutritional response.
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