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. Administration of IV antibiotics is not appropriate for this client, as there is no indication of an infection. The client's symptoms are consistent with fluid overload due to heart failure, not an infectious process.
B. Administration of IV diuretics is the priority intervention. The client is exhibiting signs of fluid overload, including jugular venous distention, crackles, and a bounding pulse. IV diuretics, such as furosemide, help reduce fluid volume, alleviate pulmonary congestion, and improve breathing.
C. Isotonic intravenous fluids would exacerbate the fluid overload and worsen the client's symptoms. This intervention is contraindicated in this scenario.
D. Laying the client supine with legs elevated is inappropriate for a client with heart failure and fluid overload, as it can increase venous return to the heart and worsen pulmonary congestion. Instead, the client should be positioned upright to improve breathing.

A. The client who has heart failure and has crackles upon lung auscultation. B. The client who has renal failure and has pitting edema. C. The client who has been NPO for 4 hours in preparation for endoscopy. D. The client who is having an exacerbation of Crohn's disease with diarrhea.

Correct Answer is D

Explanation

A. A client with heart failure and crackles in the lungs is more likely to have fluid volume excess rather than deficit.
B. A client with renal failure and pitting edema is typically at risk for fluid retention and overload, not deficit.
C. Being NPO for 4 hours is unlikely to cause significant fluid volume deficit, as this is a short period without oral intake.
D. A client with Crohn's disease experiencing diarrhea is losing significant fluids and electrolytes, placing them at high risk for fluid volume deficit. Diarrhea is a common cause of dehydration and requires close monitoring.

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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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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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