The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

Urine output of 32 mL/hour.

Confusion and disorientation.

Blood pressure of 106/82.

2+ pedal edema bilaterally.

Answer and Explanation

The Correct Answer is B

A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.

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Correct Answer is B

Explanation

A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.

A. This means that the bone broke all the way through, perpendicular to the shaft. B. This means that the bone broke in a spiral pattern. C. This means that the bone bent and only the outer arc of the bend broke. D. This means that the broken bone ends splintered into smaller pieces.

Correct Answer is C

Explanation

A. This describes a transverse fracture, where the bone breaks completely across and perpendicular to the shaft. It does not describe a greenstick fracture.
B. A spiral fracture is caused by a twisting force, which results in a helical break. This is not a greenstick fracture.
C. A greenstick fracture occurs when the bone bends and cracks on the outer arc but does not break completely through. This type of fracture is more common in children because their bones are softer and more flexible.
D. This describes a comminuted fracture, where the bone breaks into several pieces. It does not match the description of a greenstick fracture.

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The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

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Naxlex Comprehensive Predictor Exams

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