The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:

Place on cardiac monitoring.

Monitor breath sounds every 4 hours.

Restrict fluids to 500 mL per day.

Implement safety precautions.

Answer and Explanation

The Correct Answer is C

Choice A reason: Placing the client on cardiac monitoring is important, especially if there are signs of cardiac involvement or if the client is at risk for arrhythmias. However, it is not the primary intervention for hypernatremia. Hypernatremia primarily affects fluid balance and neurological status.

Choice B reason: Monitoring breath sounds every 4 hours is a good practice, particularly if there is a risk of fluid overload or respiratory complications. However, it does not directly address the issue of hypernatremia. The primary concern with hypernatremia is managing fluid balance and preventing further increases in serum sodium levels.

Choice C reason: Restricting fluids to 500 mL per day is a critical intervention for managing hypernatremia. Hypernatremia often results from a deficit in free water, leading to an elevated serum sodium level. Fluid restriction helps to prevent further increases in sodium concentration and assists in gradually correcting the imbalance. This intervention directly addresses the underlying issue of hypernatremia and helps to stabilize the client’s condition.

Choice D reason: Implementing safety precautions is important, especially if the client is experiencing neurological symptoms such as confusion or agitation. While safety precautions are necessary, they are not the primary intervention for correcting hypernatremia. The focus should be on managing fluid balance and serum sodium levels.

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Correct Answer is B

Explanation

Choice A reason:

Pulmonary function testing is not the immediate priority for a client with status asthmaticus who is showing signs of respiratory failure, such as diminished breath sounds and confusion. Pulmonary function tests are useful for diagnosing and assessing the severity of asthma but are not appropriate during an acute, life-threatening exacerbation.

Choice B reason:

Mechanical ventilation is the correct intervention for a client with status asthmaticus who is exhibiting signs of respiratory failure. Diminished breath sounds and confusion indicate severe airway obstruction and hypoxia, necessitating immediate intervention to secure the airway and ensure adequate ventilation. Mechanical ventilation helps to maintain oxygenation and ventilation until the underlying cause can be treated.

Choice C reason:

A chest x-ray can be useful in diagnosing complications such as pneumothorax or pneumonia in a client with status asthmaticus, but it is not the immediate priority when the client is showing signs of respiratory failure. The primary focus should be on stabilizing the client’s respiratory status.

Choice D reason:

Administering 2 liters of oxygen via nasal cannula is not sufficient for a client with severe status asthmaticus and signs of respiratory failure. High-flow oxygen delivery methods or mechanical ventilation are required to adequately support the client’s respiratory needs.

A. Increase the client’s intake of Vitamin C. B. Teach the client to splint the incision when coughing. C. Have the client do abdominal exercises. D. Perform passive range of motion exercises.

Correct Answer is B

Explanation

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.

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The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client with status asthmaticus, the nurse notes diminished breath sounds in all lung fields and the client is becoming confused. The nurse should prepare the client for:

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:

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