Exhibits

The practical nurse (PN) is implementing care for the client.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the PN should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Hyponatremia: The client's sodium level of 130 mEq/L is below the normal range (136–145 mEq/L), indicating hyponatremia. Symptoms like weakness, brain fog, and dehydration are typical signs. Immediate correction is necessary to prevent complications such as seizures or coma.
Metabolic Alkalosis: Metabolic alkalosis is unlikely here, as vomiting typically leads to a loss of acid, not an increase. The client's symptoms and lab results suggest hyponatremia rather than alkalosis, which doesn’t match the clinical presentation.
Hyperkalemia: The potassium level of 3.4 mEq/L is slightly below the normal range, not elevated. Hyperkalemia, which causes muscle weakness and arrhythmias, is not supported by the client's lab values, making it an unlikely diagnosis.
Hypovolemia: While the client may be experiencing hypovolemia due to fluid loss, the primary concern is hyponatremia. The signs of dehydration (poor skin turgor, dry mucous membranes) are secondary to the electrolyte imbalance, not the primary issue.
Infuse a bolus of IV fluids: Given the client’s dehydration and low sodium level, infusing a bolus of IV fluids, especially those containing sodium, is essential. This helps correct fluid loss and addresses the hyponatremia, improving hydration status and electrolyte balance.
Request prescription for antiemetic: Controlling the client’s vomiting with an antiemetic is necessary to prevent further fluid and electrolyte loss. This will allow for better fluid retention and reduce the risk of exacerbating hyponatremia and dehydration.
Monitor lab values every six hours: Regular lab tests every six hours allow for monitoring the client’s sodium and potassium levels, as well as assessing the effectiveness of the fluid resuscitation. This will ensure the condition is progressing and adjustments can be made if needed.
Neurological status: Hyponatremia can cause neurological symptoms, including confusion and lethargy. Monitoring the client’s neurological status is crucial to assess the severity of the condition and detect any worsening of symptoms that may indicate more severe imbalances.
Oral intake: Although oral intake is important, the client is likely unable to tolerate enough fluids due to vomiting. IV fluid administration is the immediate solution for rehydration, with oral intake becoming more relevant once vomiting is controlled.
Electrocardiogram: Monitoring the ECG is critical to detect arrhythmias, which can result from electrolyte imbalances like hyponatremia. Sodium and potassium disturbances can affect heart rhythms, so regular ECG monitoring helps identify any cardiac complications.
Oxygen saturation: While important, oxygen saturation is not the primary concern here. The immediate need is to correct fluid and electrolyte imbalances. Oxygen levels should still be monitored, but they are secondary to managing the hyponatremia and dehydration.

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Free Nursing Study Resources

Correct Answer is ["840"]

Explanation

Convert each fluid intake into mL:

At 0730, the client consumed 120 mL of orange juice.

At 1130, the client consumed 1 cup of broth (1 cup = 240 mL) and 120 mL of apple juice.

At 1400, the client consumed a 12-ounce can of soft drink. Since 1 ounce = 30 mL, 12 ounces equals 360 mL.

Total fluid intake:

120 mL (orange juice)

240 mL (broth)

120 mL (apple juice)

360 mL (soft drink)

Add the total fluid intake:

120 mL + 240 mL + 120 mL + 360 mL = 840 mL

Answer: 840 mL

A. Remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown. B. Confirm that turning this client once a shift is sufficient since no skin damage occurred. C. Instruct the UAP to cleanse the area thoroughly to remove any remaining skin debris. D. Gather supplies to apply a sterile dressing over the site to reduce risk for infection.

Correct Answer is A

Explanation

A. Remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown: Frequent repositioning is critical to prevent pressure injuries in bedfast clients. Although the redness blanched (indicating no permanent damage yet), regular turning is necessary to maintain skin integrity and prevent future breakdown.
B. Confirm that turning this client once a shift is sufficient since no skin damage occurred: Turning once per shift is inadequate for pressure injury prevention. Clients at risk need to be repositioned at least every two hours to minimize sustained pressure on bony prominences.
C. Instruct the UAP to cleanse the area thoroughly to remove any remaining skin debris: Since there is no open wound, aggressive cleansing is unnecessary and could actually irritate the skin further. The focus should be on pressure relief rather than harsh skin cleansing.
D. Gather supplies to apply a sterile dressing over the site to reduce risk for infection: A sterile dressing is not appropriate for blanchable redness without skin breakdown. Preventive measures like repositioning and pressure relief are the correct interventions at this stage.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["840"]

Explanation

Correct Answer is A

Explanation

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