The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Administer 0.45% NS at 50 mL/hr

Obtain daily weight

Maintain seizure precautions

Administer 3% saline as ordered

Encourage fluid intake

Answer and Explanation

Correct Answer : B,C,D

Choice A Reason:

Administering 0.45% NS (normal saline) at 50 mL/hr is not appropriate for a client with SIADH. This hypotonic solution can exacerbate the condition by increasing the water retention and further diluting the serum sodium levels, worsening hyponatremia. Instead, fluid restriction and hypertonic saline (such as 3% saline) are typically used to manage SIADH.

Choice B Reason:

Obtaining daily weight is crucial in managing SIADH. Daily weights help monitor fluid retention and detect any sudden changes in body weight, which can indicate worsening fluid overload or effective treatment. Accurate weight measurements are essential for assessing the client’s fluid balance and guiding treatment decisions.

Choice C Reason:

Maintaining seizure precautions is necessary for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if a seizure occurs.

Choice D Reason:

Administering 3% saline as ordered is appropriate for treating severe hyponatremia in SIADH. Hypertonic saline helps increase serum sodium levels and reduce the risk of neurological complications. It must be administered carefully and under close monitoring to avoid rapid correction of sodium levels, which can lead to osmotic demyelination syndrome.

Choice E Reason:

Encouraging fluid intake is not appropriate for clients with SIADH. Fluid restriction is a key component of managing SIADH to prevent further dilution of serum sodium levels. Encouraging fluid intake would counteract this goal and worsen the client’s condition.

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Correct Answer is ["C","D","E"]

Explanation

Choice A Reason:

Provide continued sedation.

Providing continued sedation is not typically necessary after a cardioversion. The sedation used during the procedure is usually short-acting, and the client should begin to wake up shortly after the procedure is completed. Continuous sedation is not required unless there are specific medical reasons, which should be determined by the healthcare provider.

Choice B Reason:

Remove crash cart from the room.

The crash cart should remain in the room until the client is fully stable. Removing it immediately after the procedure is not advisable because the client may still be at risk for complications such as arrhythmias or other cardiac events. Keeping the crash cart nearby ensures that emergency equipment is readily available if needed.

Choice C Reason:

Assess the chest for burns.

Assessing the chest for burns is an important nursing action following a cardioversion. The electrical shock delivered during the procedure can cause burns on the skin where the electrodes were placed. It is essential to check for any signs of burns or skin irritation and provide appropriate care if needed.

Choice D Reason:

Ensure electrodes are in place for continued monitoring.

Ensuring that the electrodes are in place for continued monitoring is crucial. Continuous cardiac monitoring is necessary to observe the client’s heart rhythm and detect any potential complications or recurrence of arrhythmias. Proper placement and function of the electrodes are essential for accurate monitoring.

Choice E Reason:

Document results of the procedure.

Documenting the results of the procedure is a critical nursing action. Accurate documentation includes noting the client’s response to the cardioversion, any complications, and the current heart rhythm. This information is vital for ongoing care and communication with the healthcare team.

A. Hemoptysis B. High-pitched holosystolic murmur C. Hepatomegaly

Correct Answer is A

Explanation

Choice A Reason:

Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.

Choice B Reason:

A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.

Choice C Reason:

Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.

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The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D","E"]

Explanation

After teaching a nursing student about mitral valve stenosis and mitral valve regurgitation, the nurse identifies effective learning when the student identifies which common feature of both disorders?

Correct Answer is A

Explanation

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