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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
· Total volume: 250 mL
· Infusion time: 2 hours
· Calculation: 250 mL / 2 hours = 125 mL/hour
Correct Answer is A
Explanation
A. Antihypertensive medication is not a priority intervention for a client with a blood glucose level of 620 mg/dL, which indicates hyperglycemia, likely due to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The focus should be on correcting the hyperglycemia and preventing complications like dehydration or electrolyte imbalances.
B. Fluid replacement is essential to treat dehydration caused by hyperglycemia, as high blood glucose levels cause osmotic diuresis.
C. Potassium laboratory monitoring is crucial because insulin treatment can shift potassium into cells, potentially causing hypokalemia, so monitoring is necessary during treatment.
D. Insulin IV infusion is necessary to lower the blood glucose level in clients with severe hyperglycemia, such as in DKA or HHS.
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