Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)

Testing skin turgor.

Assessing cognition.

Monitoring urine output.

Checking deep tendon reflexes.

Asking about any abdominal pain.

Checking for the presence of fever.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Testing skin turgor assesses dehydration, not severe hyponatremia (118 mEq/L), which affects neurological status. Assessing cognition detects complications, making this incorrect, as it’s less critical than the nurse’s priority of monitoring for hyponatremia’s neurological and fluid effects.

Choice B reason: Assessing cognition is critical with a sodium level of 118 mEq/L, as severe hyponatremia causes confusion or seizures. This aligns with neurological assessment, making it a correct action the nurse should perform to prevent harm in the hyponatremic client.

Choice C reason: Monitoring urine output tracks fluid balance, vital in hyponatremia to assess for SIADH or fluid overload. This aligns with renal assessment, making it a correct action the nurse should perform to prevent harm in the client with severe hyponatremia.

Choice D reason: Checking deep tendon reflexes detects neurological changes from hyponatremia, such as hyporeflexia or seizures. This aligns with neurological monitoring, making it a correct assessment the nurse should perform to prevent harm in the client with a sodium of 118 mEq/L.

Choice E reason: Abdominal pain is unrelated to hyponatremia, which primarily affects the brain and fluid balance. Monitoring urine output is more relevant, making this incorrect, as it’s not a priority assessment for the nurse to prevent harm in the hyponatremic client.

Choice F reason: Fever may indicate infection but isn’t directly linked to hyponatremia’s neurological risks. Assessing cognition is critical, making this incorrect, as it’s less urgent than the nurse’s focus on preventing harm from severe hyponatremia’s neurological complications.

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Correct Answer is C

Explanation

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Hypertensive crisis can cause severe headache, risk for stroke, pulmonary edema, and difficulty breathing. Elevating the HOB improves cerebral perfusion, reduces intracranial pressure, and eases breathing. This is an immediate, noninvasive, airway/circulation-supportive intervention.

Choice D reason: Needed for IV antihypertensive administration, but initial safety and circulation support (C) takes priority before establishing access.

A. A 45-year-old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty. B. A 57-year-old receiving IV diuretics whose blood pressure is 88/52 mm Hg. C. A 67-year-old with nausea and vomiting who reports abdominal cramps. D. A 77-year-old with normal saline infusing at 150 mL/hr with an average hourly urine output.

Correct Answer is B

Explanation

Choice A reason: Dry mucosa and thirst suggest dehydration, but hypotension (88/52) is more life-threatening. Low blood pressure requires immediate assessment, making this incorrect, as it’s less urgent than the nurse’s priority to address the client with critical hemodynamic instability.

Choice B reason: A blood pressure of 88/52 mm Hg in a client on IV diuretics indicates severe hypotension, a life-threatening condition requiring immediate assessment. This aligns with prioritization in acute care, making it the correct client for the nurse to assess first post-shift report.

Choice C reason: Nausea, vomiting, and cramps are concerning but less urgent than hypotension (88/52), which risks organ perfusion. Low blood pressure is critical, making this incorrect, as it’s secondary to the nurse’s priority of assessing the client with unstable vitals.

Choice D reason: Normal saline at 150 mL/hr with adequate urine output is stable. Hypotension (88/52) is more critical, making this incorrect, as it’s a lower priority compared to the nurse’s need to assess the client with life-threatening low blood pressure first.

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Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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