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","F"]

Explanation

Choice A reason: Red meat is not high in potassium, so it’s safe with potassium-sparing diuretics. Citrus fruits, high in potassium, risk hyperkalemia, making this incorrect, as it’s not a food the nurse would teach the client to avoid or use cautiously.

Choice B reason: Bread has low potassium content and is safe with potassium-sparing diuretics. Salt substitutes containing potassium are riskier, making this incorrect, as it’s not a food the nurse would include in teaching for cautious use with the diuretic.

Choice C reason: Citrus fruits, like oranges, are high in potassium, risking hyperkalemia with potassium-sparing diuretics. This aligns with dietary teaching, making it a correct food the nurse would teach the client to avoid or use cautiously to prevent electrolyte imbalance.

Choice D reason: Cereal is generally low in potassium unless fortified, not requiring caution with potassium-sparing diuretics. Citrus fruits are a concern, making this incorrect, as it’s not a primary food the nurse would teach the client to limit in the diet.

Choice E reason: Eggs are low in potassium and safe with potassium-sparing diuretics. Salt substitutes pose a hyperkalemia risk, making this incorrect, as it’s not a food the nurse would include in teaching for cautious use in the client’s dietary plan.

Choice F reason: Salt substitutes often contain potassium chloride, increasing hyperkalemia risk with potassium-sparing diuretics. This aligns with dietary education, making it a correct item the nurse would teach the client to avoid or use cautiously to prevent complications.

A. Check the level of the drainage bag. B. Reposition the client to the side. C. Place the client in good body alignment. D. Check the peritoneal dialysis system for kinks. E. Contact the primary health care provider (PHCP). F. Increase the flow rate of the peritoneal dialysis solution.

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

Explanation

Choice A reason: Checking the drainage bag level ensures it’s below the abdomen to promote gravity-dependent outflow. This addresses reduced outflow in peritoneal dialysis, making it a correct action the nurse would take to resolve the inflow-outflow discrepancy safely.

Choice B reason: Repositioning to the side can dislodge catheter obstructions or improve drainage in peritoneal dialysis. This is a standard intervention for low outflow, making it a correct action the nurse would perform to correct the client’s dialysis flow issue.

Choice C reason: Good body alignment prevents catheter kinking and promotes effective drainage in peritoneal dialysis. This addresses outflow issues, making it a correct action the nurse would take to ensure proper function of the dialysis system for the client.

Choice D reason: Checking for kinks in the dialysis system identifies mechanical causes of reduced outflow. This is a key troubleshooting step, making it a correct action the nurse would perform to resolve the inflow-outflow imbalance in the client’s peritoneal dialysis.

Choice E reason: Contacting the provider is premature before troubleshooting mechanical issues like kinks or positioning. Checking the drainage bag is a priority, making this incorrect, as it delays the nurse’s initial actions to correct the dialysis outflow problem independently.

Choice F reason: Increasing the flow rate doesn’t address outflow obstruction and may worsen fluid imbalance. Repositioning is more appropriate, making this incorrect, as it’s not a safe action compared to the nurse’s focus on resolving mechanical dialysis issues 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

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

Correct Answer is ["C","F"]

Explanation

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions would the nurse take? (Select all that apply)

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

Explanation

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