The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

White blood cell count.

Serum sodium levels.

Serum potassium levels.

Creatinine clearance.

Answer and Explanation

The Correct Answer is B

A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.

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Correct Answer is A

Explanation

A. Instructing the client in the use of the PCA pump directly addresses the severe pain by allowing the client to self-administer analgesia as needed, which provides immediate relief and is crucial for effective pain management post-surgery.
B. Assisting the client in changing positions may offer temporary relief but does not address the underlying pain, which should be managed primarily through medication.
C. Initiating CPM is not an appropriate first step for managing severe pain. CPM is used for improving joint mobility and should only be considered after effective pain management is established.
D. Applying ice might provide some temporary relief, but it is not a substitute for effective pain control through medication. Addressing the pain with PCA is the priority.

A. Place the client in a Trendelenburg position. B. Document the second reading in the client record. C. Securely place the prongs of the cannula in the nostrils. D. Place the pulse oximeter on the client's earlobe.

Correct Answer is C

Explanation

A. The Trendelenburg position is not appropriate for managing low oxygen saturation levels and may not address the underlying issue. This position is more commonly used for hypotension, not hypoxemia.
B. Documenting the reading is important for record-keeping but does not address the immediate concern of the client's low oxygen saturation levels.
C. Ensuring that the nasal cannula is securely placed in the nostrils is crucial for effective oxygen delivery. A loose or improperly positioned cannula can result in inadequate oxygenation, contributing to lower oxygen saturation readings.
D. While placing the pulse oximeter on the earlobe might provide a different reading, it is essential first to ensure that the current oxygen delivery system is functioning properly and the cannula is properly positioned.

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The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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