You receive report from the off going nurse that patient L K is admited with hyponatremia. the nurse states he is becoming increasingly confused as the day goes on and management is considering restraining the patient, so he does not become a harm to himself. You assess the patient and note that the IV fluids hanging are 0.33% NaCI. What should you do next?
Bring the patient to the nurse s station so he can be watched until he regains orientation.
Get an order for additional lab work.
Call the doctor and get an order for restraints.
Disconnect the IV fluids immediately they are dropping his Na+ levels.
The Correct Answer is B
Hyponatremia is a condition where the sodium levels in the blood are abnormally low. It can cause confusion, seizures, and even coma in severe cases. The IV fluids hanging are 0.33% NaCI, which means they have a low sodium concentration, and may be contributing to the patient's hyponatremia.
Given that the patient is becoming increasingly confused, it is important to assess his mental status and monitor him closely to prevent harm. However, restraining the patient should not be the first course of action. Instead, the nurse should focus on identifying the underlying cause of the hyponatremia and taking appropriate steps to address it.
Therefore, the next step would be to get an order for additional lab work to assess the patient's electrolyte levels and identify the cause of the hyponatremia. This will help to guide further treatment and management decisions for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Stridor is a high-pitched, inspiratory sound that indicates partial obstruction of the upper airway. It is a common finding in newborns and can occur due to the presence of mucus, fluid, or a small airway that has not yet fully developed. It is important to note that while stridor is an expected finding in newborns, it should still be assessed and monitored closely by healthcare professionals.
Bruits are abnormal sounds heard over blood vessels and are not related to breath sounds. Crackles are a series of brief, discontinuous, nonmusical sounds heard during inspiration or expiration, indicating fluid in the lungs. Wheezing is a high-pitched, musical sound heard during expiration and can indicate the narrowing of the airways. These sounds are not typically expected in the breath sounds of a newborn.
Correct Answer is B
Explanation
. Assess your patient’s lower extremities and lungs for fluid retention.
If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for fluid retention. This can help determine if the patient is retaining water and if further intervention is necessary.
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