The client is admitted with a serum sodium level of 110 mEq/L. What nursing intervention should be implemented?
Administer 10% sodium chloride via rapid infusion
Administer intranasal antidiuretic hormone
Encourage oral fluid intake
Place the client on seizure precautions
The Correct Answer is D
A. Administer 10% sodium chloride via rapid infusion: Rapid infusion of high concentrations of sodium chloride can be dangerous and is not the standard treatment for severe hyponatremia.
B. Administer intranasal antidiuretic hormone: This would not be appropriate for correcting severe hyponatremia and could potentially worsen the condition.
C. Encourage oral fluid intake: For severe hyponatremia, oral fluid intake might not be sufficient and could exacerbate the condition if there is fluid overload.
D. Place the client on seizure precautions: This is the correct choice. Severe hyponatremia (sodium < 120 mEq/L) can lead to neurological symptoms and seizures, so implementing seizure precautions is crucial for safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chest x-ray results: This is the correct choice. After central venous catheter insertion, a chest x-ray is crucial to confirm correct catheter placement and to rule out complications such as pneumothorax or catheter malposition.
B. Serum osmolality: While serum osmolality can provide information about fluid and electrolyte balance, it is not directly related to verifying catheter placement or the immediate post-insertion assessment.
C. Intake and output record: Although important for monitoring fluid balance, the intake and output record does not confirm the proper placement of the central venous catheter.
D. Serum glucose level: This is not relevant to verifying the catheter placement or ensuring proper functioning immediately after insertion.
Correct Answer is D
Explanation
A. The 22-year-old client who does not understand English: This client can still consent legally if provided with a translator or interpreter to ensure understanding.
B. The 17-year-old client who has two fractured wrists: This client is a minor and would typically need a legal guardian to consent, but their ability to consent is not the primary issue here.
C. The 65-year-old client who cannot read or write: Literacy issues do not necessarily preclude the ability to understand and consent, especially if the consent process is explained to them.
D. The 80-year-old client who is not oriented to the day: This client lacks orientation and thus may not be able to fully understand or make an informed decision about the surgery, affecting their ability to consent legally.
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