A nurse is evaluating the effectiveness of fluid therapy for a client who has hypernatremia. Which of the following findings indicates improvement? (Select all that apply.)

Decreased thirst.

Increased urine output.

Decreased serum sodium level.

Increased level of consciousness.

Decreased edema.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Decreased thirst. This is a sign of improvement because hypernatremia causes increased thirst due to high sodium levels in the blood. Decreased thirst indicates that the fluid therapy has restored the normal balance of sodium and water in the body.

Choice B reason:

Increased urine output. This is a sign of improvement because hypernatremia can cause decreased urine output due to dehydration or kidney dysfunction. Increased urine output indicates that the fluid therapy has replenished the body's water and helped the kidneys excrete excess sodium.

Choice C reason:

Decreased serum sodium level. This is a sign of improvement because hypernatremia is defined as a serum sodium level higher than 145 mEq/L. Decreased serum sodium level indicates that the fluid therapy has diluted the blood and lowered the sodium concentration to within the normal range.

Choice D reason:

Increased level of consciousness. This is a sign of improvement because hypernatremia can cause confusion, lethargy, or coma due to the effects of high sodium levels on the brain. Increased level of consciousness indicates that the fluid therapy has improved the brain function and reduced the risk of brain injury.

Choice E reason:

Decreased edema. This is not a sign of improvement because hypernatremia does not cause edema, which is the accumulation of fluid in the interstitial spaces. Edema is more likely to occur in conditions such as hypervolemia (excess fluid volume) or hyponatremia (low sodium levels) Decreased edema may indicate that the fluid therapy has caused fluid overload or electrolyte imbalance, which can be harmful.

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Correct Answer is D

Explanation

Choice A reason: Shaving the hair around the insertion site is not recommended because it can cause skin irritation and increase the risk of infection.

Choice B reason:

Obtaining informed consent from the patient is important, but it is not a step that the nurse should perform before inserting the catheter. Informed consent should be obtained by the physician or advanced practice nurse who will perform the procedure.

Choice C reason:

Administering prophylactic antibiotics to the patient is not a routine practice for central venous catheter insertion. Antibiotics may be indicated for patients with certain risk factors, such as immunosuppression, but they should be prescribed by the physician or advanced practice nurse.

Choice D reason:

Placing the patient in Trendelenburg position is an important step that the nurse should perform before inserting the catheter. This position helps to distend the jugular vein and reduce the risk of air embolism during catheter insertion.

A. Jugular vein distension. B. Weight gain of 2 kg in one day. C. Decreased hematocrit. D. Bounding pulse. E. Flat neck veins.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Jugular vein distension is a sign of fluid overload because it indicates increased pressure in the right atrium and superior vena cava due to excess blood volume.

Choice B reason:

Weight gain of 2 kg in one day is a sign of fluid overload because it reflects fluid retention in the body. A weight gain of 1 kg (2.2 lb) is equivalent to 1 L of fluid.

Choice C reason:

Decreased hematocrit is a sign of fluid overload because it indicates hemodilution or dilution of the blood due to excess fluid in the intravascular space.

Choice D reason:

Bounding pulse is a sign of fluid overload because it reflects increased cardiac output and stroke volume due to excess blood volume.

Choice E reason:

Flat neck veins are not a sign of fluid overload, but rather a sign of fluid deficit or dehydration. In fluid overload, neck veins will be distended or elevated.

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A nurse is evaluating the effectiveness of fluid therapy for a client who has hypernatremia. Which of the following findings indicates improvement? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to insert a central venous catheter into a patient's right internal jugular vein using ultrasound guidance. What is an important step that the nurse should perform before inserting the catheter?

Correct Answer is D

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse report to the provider? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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