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 D
Explanation
A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention
Correct Answer is B
Explanation
A. 5-hour urine output total of 300 mL: This urine output is low, but it may not immediately indicate a serious issue without additional context. However, monitoring for adequate urine output is important.
B. Serum potassium level of 3.0 mEq/L: This is the correct choice. A serum potassium level of 3.0 mEq/L indicates hypokalemia, a serious side effect of furosemide, which can lead to cardiac arrhythmias and requires immediate intervention.
C. Current blood pressure of 141/80 mm Hg: Although the blood pressure is still elevated, it is not as urgent as correcting hypokalemia. The medication’s effectiveness should be monitored, but it is not an immediate concern.
D. Serum glucose level of 135 mg/dL: This level is slightly elevated but not critically high, and it does not require immediate action related to furosemide use.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.