The nurse understands which of the following actions is an effective treatment approach for SIADH?
Administering diuretics to promote diuresis and eliminate excess fluid.
Increasing fluid intake to promote dilution of electrolytes.
Restricting fluid intake to prevent fluid overload.
Administering hypertonic 3% saline to restore electrolyte balance.
Correct Answer : C,D
Choice A rationale
Administering diuretics in SIADH can worsen hyponatremia by promoting water excretion with a concomitant loss of sodium, further diluting serum sodium concentration. The underlying issue in SIADH is excessive antidiuretic hormone leading to water retention, not primarily excess extracellular fluid that needs diuresis.
Choice B rationale
Increasing fluid intake is contraindicated in SIADH. The syndrome involves excessive reabsorption of water, leading to dilutional hyponatremia and fluid overload. Increasing fluid intake would exacerbate these issues, further lowering serum sodium levels and potentially leading to cerebral edema.
Choice C rationale
Restricting fluid intake is a cornerstone of SIADH management. By limiting water intake, the body's excessive water retention is mitigated, allowing serum sodium concentration to rise towards normal levels. This helps prevent further dilution of electrolytes and reduces the risk of fluid overload and cerebral edema.
Choice D rationale
Administering hypertonic 3% saline is an effective treatment for symptomatic severe hyponatremia in SIADH. This solution provides a concentrated source of sodium, helping to raise serum sodium levels by drawing water out of cells and into the extracellular space, thereby correcting the dilutional hyponatremia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A ventilator-dependent patient requires complex and specialized respiratory care, including ventilator management, suctioning, and frequent assessments for complications such as pneumonia or acute respiratory distress syndrome. This level of care demands advanced knowledge and experience in critical care, which a nurse with only six months of experience floated from a surgical unit may not possess, potentially compromising patient safety.
Choice B rationale
A patient recently returned from a bronchoscopy and biopsy is at risk for immediate post-procedure complications such as hemorrhage, pneumothorax, or respiratory distress. These potential acute events require prompt and skilled assessment, intervention, and monitoring, which necessitate an experienced nurse with a strong understanding of respiratory physiology and post-procedural care, beyond what a novice nurse might have.
Choice C rationale
A patient on airborne precautions for tuberculosis requires meticulous adherence to infection control protocols to prevent disease transmission. This includes proper use of N95 respirators, negative pressure rooms, and visitor management. While important, managing airborne precautions is a critical skill. However, a nurse with only six months of experience and floated from a surgical unit may not have sufficient experience with medical unit patient acuity or the complexities of managing a communicable disease.
Choice D rationale
Teaching about incentive spirometry is a routine and relatively low-risk intervention, focusing on patient education and demonstrating proper technique. This task aligns well with the skill set of a nurse with six months of experience, even if floated from another unit, as it does not typically involve complex assessments or high-acuity interventions, making it an appropriate assignment for skill reinforcement and patient engagement.
Correct Answer is ["B","C","H"]
Explanation
Signs: "increasingly confused and irritable", "tremors in the client's hands when arms are extended", "The client with cirrhosis appears disoriented and has difficulty answering simple asks", "The nurse observes asterixis when the client extends their arms", "The nurse monitors the client closely for worsening neurologic functions.”. Causes: "cirrhosis", "elevated mental status" (This phrase is likely a typo and should refer to elevated ammonia levels, which is the primary cause of hepatic encephalopathy). Treatments: "The provider prescribes lactulose to lower ammonia levels.”.
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