A patient is receiving 3% NaCl solution for correction of hyponatremia.For which of the following will the nurse assess?
Hypokalemia.
Hypovolemia.
Fluid overload.
Hypernatremia.
The Correct Answer is C
Choice A rationale
Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.
Choice B rationale
Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.
Choice C rationale
Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.
Choice D rationale
Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation of central tissues. When there is a lack of oxygen in the bloodstream, the lips and mucous membranes, such as the oral mucosa, appear blue or cyanotic. This is a clear sign that the central tissues are not receiving adequate oxygenation.
Choice B rationale
The sclera of the eye is not a reliable indicator of central cyanosis. The sclera is white and does not change color due to oxygen levels. Instead, it may become yellow in jaundice or red in inflammation but does not reflect central cyanosis.
Choice C rationale
The ear lobes are peripheral areas and do not reliably indicate central cyanosis. Peripheral cyanosis can occur due to local blood flow issues, and ear lobes can appear blue in cold conditions even when central oxygenation is normal.
Choice D rationale
The soles of the feet, similar to the ear lobes, are peripheral areas and not reliable indicators of central cyanosis. Cyanosis in the feet can result from poor peripheral circulation rather than central hypoxia.
Correct Answer is D
Explanation
Choice A rationale
Taking nitroglycerin when experiencing chest pain is correct as it helps to relieve the pain by dilating blood vessels and increasing blood flow to the heart.
Choice B rationale
Calling 911 if chest pain does not improve after taking nitroglycerin is correct and necessary to seek immediate medical assistance.
Choice C rationale
Storing nitroglycerin tablets in a dark, cool place is correct to maintain their potency, as light and heat can degrade the medication.
Choice D rationale
Taking up to three doses of nitroglycerin five minutes apart is correct; however, if the pain persists after one dose, the patient should call 911 immediately rather than waiting for all three doses to be taken.
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