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:

Fever and bradypnea are not typical manifestations of asthma. Fever is more commonly associated with infections, and bradypnea (abnormally slow breathing) is not a characteristic symptom of asthma.

Choice B reason:

Dyspnea (shortness of breath) and wheezing are hallmark symptoms of asthma. Asthma is characterized by inflammation and narrowing of the airways, which leads to difficulty breathing and a whistling sound (wheezing) when exhaling. These symptoms are often triggered by allergens, exercise, or respiratory infections.

Choice C reason:

Crackles and a productive cough are more indicative of conditions like pneumonia or chronic bronchitis rather than asthma. Asthma typically involves a dry cough rather than a productive one.

Choice D reason:

A normal chest shape and orthopnea (difficulty breathing when lying flat) are not specific to asthma. While some individuals with severe asthma may develop a barrel chest over time due to chronic overinflation of the lungs, this is not a typical early manifestation.

A. Exercise B. Pollen C. Animal dander D. Emotional stress E. Recent travel abroad

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Exercise is a well-known trigger for asthma, particularly exercise-induced bronchoconstriction (EIB). During physical activity, especially in cold or dry air, the airways can narrow, leading to symptoms such as shortness of breath, wheezing, and coughing. Proper management and pre-exercise medication can help mitigate these effects.

Choice B reason:

Pollen is a common allergen that can trigger asthma symptoms. Pollen from trees, grasses, and weeds can cause allergic reactions that lead to asthma exacerbations. Seasonal variations in pollen levels can significantly impact individuals with asthma, making it important to monitor pollen counts and take preventive measures.

Choice C reason:

Animal dander, which consists of tiny flakes of skin shed by cats, dogs, and other animals, is a frequent asthma trigger. Proteins found in the dander, saliva, and urine of pets can cause allergic reactions and asthma symptoms. Reducing exposure to pets and maintaining a clean environment can help manage this trigger.

Choice D reason:

Emotional stress can also trigger asthma symptoms. Stress and strong emotions can lead to hyperventilation and changes in breathing patterns, which can exacerbate asthma. Stress management techniques and relaxation exercises can be beneficial in controlling asthma symptoms related to emotional stress.

Choice E reason:

Recent travel abroad is not typically considered a common trigger for asthma. While travel can expose individuals to different environmental factors and allergens, it is not a direct trigger like the other options listed. However, it is important for individuals with asthma to plan and prepare for travel to manage their condition effectively.

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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

The nurse is completing an admission assessment on a client diagnosed with asthma. What clinical manifestations are typical of the disorder?

Correct Answer is B

Explanation

Which of the following would the nurse discuss as common triggers for a client newly diagnosed with asthma? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D"]

Explanation

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