Which assessment finding is most indicative of hypernatremia?

Ascending muscle weakness

Muscle tetany and hyperreflexia

Poor turgor and dry mucous membranes

Bradycardia and hypotension

Answer and Explanation

The Correct Answer is C

A. Ascending muscle weakness is more characteristic of hypokalemia (low potassium levels) rather than hypernatremia.
B. Muscle tetany and hyperreflexia are typically seen in hypocalcemia (low calcium levels) or hypomagnesemia (low magnesium levels), not hypernatremia.
C. Hypernatremia (high sodium levels) commonly causes dehydration, which results in poor skin turgor and dry mucous membranes. This is a key clinical sign of hypernatremia.
D. Bradycardia and hypotension are more commonly associated with hypovolemia (low blood volume) or hypotension, but they are not specific to hypernatremia.

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Correct Answer is D

Explanation

A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.

A. 50% Dextrose in Water (D50W) IV push B. Insulin Regular IV push C. 0.9% sodium chloride infusion D. 5% Dextrose continuous IV infusion

Correct Answer is A

Explanation

A. 50% Dextrose in Water (D50W) IV push is the most appropriate intervention for a client with a blood glucose level of 30 mg/dL, indicating severe hypoglycemia. The rapid administration of D50W will quickly raise the blood glucose level and help restore consciousness.
B. Insulin Regular IV push would lower the blood glucose level, which is not appropriate in this situation where the client is hypoglycemic.
C. 0.9% sodium chloride infusion is a general fluid replacement solution, but it will not address the client's low blood glucose level.
D. 5% Dextrose continuous IV infusion is typically used for maintenance, but it would not act as quickly as D50W to correct severe hypoglycemia in an unconscious patient.

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Which assessment finding is most indicative of hypernatremia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?

Correct Answer is D

Explanation

The nurse is caring for a client who is diabetic and has a blood glucose level of 30 mg/dL. The client is unconscious and has a 20-gauge peripheral IV in the antecubital area. After securing the client's airway, what medication should the nurse plan to administer first?

Correct Answer is A

Explanation

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