The nursing care for a patient with hyponatremia and fluid volume excess includes:

Administration of hypotonic fluids

Placement of an indwelling catheter

Administration of calcium gluconate

Fluid Restriction

Answer and Explanation

The Correct Answer is D

A. Administration of hypotonic fluids: Hypotonic fluids would worsen hyponatremia by further diluting the sodium concentration in the blood. This intervention is contraindicated in patients with both low sodium levels and fluid overload.

B. Placement of an indwelling catheter: While a catheter may be used for monitoring output, it does not address fluid volume excess or hyponatremia. Invasive devices should only be used when clinically necessary and not as a primary treatment.

C. Administration of calcium gluconate: Calcium gluconate is used to manage hyperkalemia or hypocalcemia, not hyponatremia. It has no therapeutic effect in correcting sodium imbalance or fluid volume excess.

D. Fluid restriction: Restricting fluids is the appropriate treatment for a patient with hyponatremia and fluid overload. It helps prevent further dilution of sodium and reduces excess fluid in the body, aiding in restoring balance.

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Correct Answer is B

Explanation

A. Patient lives with her partner in a one-story home: Living in a one-story home is not inherently a risk factor for sensory deficits. The home environment may impact mobility, but it does not directly contribute to vision, hearing, or other sensory issues.

B. Patient reports she worked in the military as an airplane mechanic: Working in the military as an airplane mechanic may expose the patient to high noise levels, which can cause hearing loss over time. Prolonged exposure to loud noises is a significant risk factor for sensory deficits, particularly for hearing.

C. Patient recently had grab rails installed in her bathroom: The installation of grab rails is a safety measure to reduce the risk of falls and is not directly related to sensory deficits. While it is a precautionary action, it does not indicate any sensory impairment or risk for deficits.

D. Patient schedules annual eye exams with her ophthalmologist: Regular eye exams are preventive measures that help detect sensory deficits early, particularly vision problems. This behavior indicates a proactive approach to maintaining eye health, not sensory deficits.

A. Lung sounds B. Activity level C. Skin turgor D. Heart sounds

Correct Answer is C

Explanation

A. Lung sounds: While important for respiratory assessment, lung sounds are not directly affected by diarrhea or dehydration unless complications such as aspiration or infection develop, which are less common in this context.

B. Activity level: Changes in activity may occur due to weakness or fatigue caused by fluid and electrolyte imbalances, but this is a less specific and less immediate indicator of dehydration risk.

C. Skin turgor: Assessing skin turgor helps evaluate hydration status. Poor skin turgor indicates fluid loss and dehydration, which is a common risk with prolonged diarrhea and can lead to more serious complications if untreated.

D. Heart sounds: Heart sounds can reveal cardiac abnormalities, but they are not the primary focus in assessing dehydration. However, monitoring heart rate and rhythm can provide additional information about circulatory status in severe cases.

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The nursing care for a patient with hyponatremia and fluid volume excess includes:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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