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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Notify the nursing board: Reporting to the nursing board is necessary for ongoing professional accountability but is not the immediate first step. The priority is to ensure the safety of clients by addressing the situation within the facility first.
B. Submit an incident report: An incident report documents the event, but it should be completed after immediate concerns for client safety are addressed. It is not the first action when dealing with an impaired nurse.
C. Email the nurse manager: Emailing the nurse manager may delay the response. Immediate verbal communication with someone in a supervisory role is essential to remove the impaired nurse from client care duties without delay.
D. Inform the charge nurse: Informing the charge nurse immediately is the priority because the charge nurse has the authority to intervene quickly, ensure the impaired nurse is removed from duty, and maintain patient safety. This allows for appropriate administrative steps to follow afterward.
Correct Answer is B
Explanation
A. Extend thumb at a right angle during gloving: Positioning the thumb may help with glove placement but does not directly maintain surgical asepsis. The focus of aseptic technique is keeping gloves sterile, not thumb positioning during the process.
B. Keep gloved hands in sight above waist level: Keeping hands in sight and above waist level is essential for maintaining surgical asepsis. Anything below waist level is considered contaminated, and visibility ensures that sterility is not compromised during procedures.
C. Touch cuff fold only while applying second glove: Touching the cuff is appropriate when donning the second glove, but maintaining hand position above waist level is a broader and ongoing requirement to uphold sterile technique throughout the procedure.
D. Apply a mask once both hands are gloved: Masks should already be in place before starting the sterile gloving procedure. Waiting to apply a mask after donning sterile gloves risks contaminating the gloves and breaking sterile technique.
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