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 B

Explanation

Choice A reason: Assessing pain at the insertion site is important but less urgent than ensuring vascular patency post-catheterization. Checking pulses detects complications like occlusion, making this incorrect, as it’s secondary to the nurse’s priority of monitoring for vascular issues immediately post-procedure.

Choice B reason: Assessing dorsalis pedis and posterior tibial pulses is most important to detect vascular complications, such as arterial occlusion, post-cardiac catheterization. This aligns with post-procedure protocols, making it the correct action to ensure limb perfusion and prevent serious complications immediately.

Choice C reason: Observing the access site for bleeding is key but secondary to ensuring distal perfusion via pulses. Vascular occlusion is a greater risk, making this incorrect, as it’s less urgent than the nurse’s priority of checking pulses post-cardiac catheterization.

Choice D reason: Checking capillary refill time assesses perfusion but is less specific than pulse assessment for detecting arterial issues post-catheterization. Pulses are the priority, making this incorrect, as it’s secondary to the nurse’s focus on immediate vascular integrity post-procedure.

A. A client diagnosed with bipolar disorder receiving lithium carbonate (Lithobid). B. A client diagnosed with renal artery stenosis receiving losartan (Cozaar). C. A client diagnosed with lung cancer receiving vincristine (Oncovin). D. A client diagnosed with hyperthyroidism receiving methimazole (Tapazole).

Correct Answer is C

Explanation

Choice A reason: Lithium can cause nephrogenic diabetes insipidus, not SIADH, which involves excess ADH. Lung cancer is a known SIADH trigger, making this incorrect, as it’s unrelated to the syndrome compared to the high-risk client with cancer and vincristine therapy.

Choice B reason: Losartan treats hypertension in renal artery stenosis but doesn’t cause SIADH, which is linked to cancers. Lung cancer with vincristine is riskier, making this incorrect, as it’s not associated with the syndrome in the nurse’s risk assessment of clients.

Choice C reason: Lung cancer, especially small cell, and vincristine are strongly associated with SIADH due to ectopic ADH production. This aligns with oncology risk factors, making it the correct client most at risk for SIADH in the nurse’s outpatient clinic care.

Choice D reason: Hyperthyroidism and methimazole don’t typically cause SIADH, unlike lung cancer’s strong link. Vincristine-treated cancer is the highest risk, making this incorrect, as it’s not a primary cause of SIADH in the nurse’s evaluation of the outpatient clients.

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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)

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