The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?
"Do you drink milk or eat dairy products at each meal?"
"How much water and ice chips do you have each day?"
"What amount of your daily meals contains fresh vegetables?"
"How frequently do you eat processed or canned foods?"
The Correct Answer is B
Choice A reason: Asking about the consumption of milk or dairy products is not directly related to the client's serum sodium level. Dairy intake does not typically cause significant changes in sodium levels. Therefore, this question would not help in identifying the cause of the hyponatremia.
Choice B reason: This question is most relevant because excessive water or ice chip intake can lead to dilutional hyponatremia. Ingestion of large amounts of water can dilute the sodium concentration in the blood, resulting in a low serum sodium level. Identifying excessive fluid intake is critical in determining if this is the cause of the client's hyponatremia.
Choice C reason: Inquiring about the number of fresh vegetables in the client's diet is more related to overall nutrition rather than directly linked to sodium levels. While vegetables can be part of a healthy diet, this question would not specifically address the cause of a low serum sodium level.
Choice D reason: The frequency of consuming processed or canned foods, which are typically high in sodium, would generally be expected to increase serum sodium levels rather than decrease them. Therefore, this question does not directly address the issue of a low sodium level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Washing hands with warm soapy water before sticking the finger is a critical step in the process of self-monitoring blood glucose. Clean hands help prevent infections and ensure that the blood sample is not contaminated, which can affect the accuracy of glucose readings. This practice indicates that the client understands and can effectively follow the proper procedure for SMBG.
Choice B reason: Using a lancing device on the centre of the finger pad is not the correct technique. The sides of the finger pads are recommended for pricking because they are less sensitive than the centre and can provide a better sample with less discomfort. This indicates a misunderstanding of the correct procedure.
Choice C reason: Informing the healthcare provider of average haemoglobin A1C results weekly is unnecessary. Haemoglobin A1C is typically measured every 3 to 6 months to monitor long-term glucose control. Weekly reporting is not required and shows a lack of understanding about the appropriate use of A1C measurements.
Choice D reason: Documenting haemoglobin A1C results from the SMBG monitor every morning is incorrect. The SMBG monitor measures daily blood glucose levels, not haemoglobin A1C. Haemoglobin A1C provides an average blood glucose level over the past 2 to 3 months and is not obtained from daily SMBG readings.
Correct Answer is C
Explanation
Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.
Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.
Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.
Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.
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