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 ["75"]
Explanation
- Total volume: 1800 mL
- Infusion time: 24 hours
- Calculation: 1800 mL / 24 hours = 75 mL/hour
Therefore, the IV pump should be set to deliver 75 mL/hr.
Correct Answer is D
Explanation
A. Dextrose in water is typically used for hydration and to provide some calories. However, this client is presenting with hypotension (BP 88/56), tachycardia (Pulse 110), and weakness, likely due to fluid loss from vomiting. This client needs fluid resuscitation with a solution that will help restore circulating volume, and Dextrose in water does not contain sodium, which is necessary for fluid balance in this case.
B. 6.45% Sodium Chloride is a hypertonic saline solution, which would increase the osmolarity of the blood and pull fluid into the bloodstream. This would not be the first choice for this patient, as it could exacerbate dehydration and electrolyte imbalances.
C. 10% Dextrose in water is also a hypertonic solution that would provide energy but would not adequately address the client's fluid volume deficit or hypotension.
D. 0.9% Sodium Chloride is normal saline, which is an isotonic solution and is the most appropriate choice for fluid resuscitation in this client. It will help restore circulating blood volume, stabilize blood pressure, and provide the necessary hydration to address the client's symptoms of dehydration.
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