A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching?

"Weigh yourself every morning and every night."

"Check your radial pulse twice a day."

"Read food labels to determine sodium content."

"Bake or grill the meat rather than frying it."

Answer and Explanation

The Correct Answer is C

A. "Weigh yourself every morning and every night.": While weight monitoring is important in conditions like fluid retention, hypernatremia is related to sodium levels, not fluid retention. The nurse should focus more on sodium intake than daily weight checks.

B. "Check your radial pulse twice a day.": Checking the radial pulse might be helpful for monitoring heart rate or signs of dehydration, but it does not directly address the management of hypernatremia. Focusing on sodium intake is more relevant.

C. "Read food labels to determine sodium content.": Sodium intake is a key factor in managing hypernatremia. Teaching the client to read food labels will help them identify foods high in sodium, which is critical to controlling their sodium levels and preventing worsening hypernatremia.

D. "Bake or grill the meat rather than frying it.": While baking or grilling meat is a healthier cooking method, it does not address the management of hypernatremia. Reducing sodium intake through food choices is more directly related to managing this condition.

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Correct Answer is D

Explanation

A. Moist skin: Dehydration typically causes the skin to become dry, not moist. In fluid volume deficit, the body loses water and electrolytes, leading to a lack of moisture in the skin.

B. Distended neck veins: Distended neck veins are typically a sign of fluid volume excess or overload, such as in heart failure, not fluid volume deficit. Dehydration usually leads to decreased blood volume, which results in flat veins.

C. Increased urinary output: Dehydration leads to decreased urine output as the body attempts to conserve water. Increased urinary output would be seen in conditions like diabetes insipidus, not dehydration.

D. Thready pulses: Thready pulses are a common sign of dehydration. Fluid volume deficit reduces circulating blood volume, leading to weaker and less palpable pulses, which is characteristic of dehydration.

A. Avoid hanging the IV with K and inform the registered nurse (RN) of the urine output. B. Run the IV rapidly for 30 minutes to stimulate urine production. C. Call the physician who ordered the K+. D. Hang the IV as ordered and chart the output.

Correct Answer is A

Explanation

A. Avoid hanging the IV with K and inform the registered nurse (RN) of the urine output: The low urine output suggests potential renal impairment, which could lead to potassium retention. Administering potassium could cause dangerous hyperkalemia, so it’s important to hold the IV and consult the RN for further evaluation.

B. Run the IV rapidly for 30 minutes to stimulate urine production: Rapid infusion could worsen fluid overload or cause other complications, and it will not address the renal issue causing the low urine output. Potassium should be avoided to prevent complications.

C. Call the physician who ordered the K+: While notifying the physician is important, the immediate priority is to inform the RN, as the potassium infusion should be withheld until renal function is assessed and corrected, if necessary.

D. Hang the IV as ordered and chart the output: Hanging the IV with potassium is risky in this case, as the client may not be able to eliminate potassium due to decreased renal function. Monitoring urine output is crucial before proceeding with potassium administration.

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A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is dehydrated due to fluid volume deficit. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A licensed practical/vocational nurse (LPN/LVN) is preparing to add a new IV of 5% dextrose in water (D5W) with potassium (K) to an existing line. The LPN/LVN notices that only 25 mL of urine has been collected over the past hour. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

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