Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

Dry skin with inelastic turgor.

Apical rate of 110 beats/minute.

Serum sodium of 185 mEq/L (185 mmol/L).

Polyuria and excessive thirst.

Answer and Explanation

The Correct Answer is C

Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.

Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.

Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.

Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.

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Correct Answer is C

Explanation

Choice A reason: Administering a PRN narcotic at 9 cm dilation is inappropriate, as labor is in transition, nearing delivery. Narcotics risk fetal respiratory depression, crossing the placenta, especially with a stable fetal heart rate (120 beats/minute). Preparing for imminent delivery is critical, prioritizing a safe birth environment over pain relief.

Choice B reason: Asking the husband to leave does not address the client’s advanced labor (9 cm, 100% effaced, frequent contractions). His presence may provide support, and removal could increase distress. Setting up the delivery table is urgent, as birth is imminent, ensuring a sterile, safe environment for delivery.

Choice C reason: At 9 cm dilation, 100% effacement, and contractions every 2 minutes, the client is in transition, with delivery imminent. Setting up the delivery table ensures readiness for vaginal birth, providing a sterile field and equipment, addressing the physiological progression of labor for safe delivery of the newborn.

Choice D reason: Notifying the rapid response team is unnecessary, as the fetal heart rate (120 beats/minute) is normal (110–160), and screaming reflects labor pain. Delivery is imminent, making table setup the priority to facilitate safe birth, avoiding escalation to emergency response for a normal labor progression.

A. Discourage straining on stool. B. Medicate with PRN IV narcotic. C. Initiate infusion for an IV fluid bolus. D. Administer an IV antiemetic.

Correct Answer is B

Explanation

Choice A reason: Discouraging straining on stool prevents pain exacerbation or constipation in cancer but is not the priority with a pain score of 9. Severe pain from bone metastases, stimulating nociceptors, requires urgent IV narcotics to improve comfort, addressing the primary palliative goal over secondary issues like straining.

Choice B reason: A pain score of 9 in metastatic bone cancer indicates severe nociceptive pain from tumor invasion. IV narcotics (e.g., morphine) rapidly bind opioid receptors, reducing pain perception. This prioritizes comfort in palliative care, especially with stable vitals (SpO₂ 95%), addressing pain before nausea in this critical scenario.

Choice C reason: An IV fluid bolus treats dehydration from vomiting but does not address severe pain (9/10), a palliative priority. Bone metastases cause intense pain, requiring narcotics. Fluids are secondary, as vitals (BP 110/80) suggest stability, making pain relief more urgent to enhance quality of life in palliative care.

Choice D reason: An IV antiemetic controls nausea, likely from tumor or treatment effects, but severe pain (9/10) is the priority in palliative care. Narcotics provide rapid relief for bone metastasis pain, improving comfort. Antiemetics are secondary, as pain significantly impacts quality of life more immediately than nausea.

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Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

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Naxlex Comprehensive Predictor Exams

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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