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A client at risk for mild hypernatremia is being taught by a nurse. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. Check your radial pulse twice a day
- C. Read food labels to determine sodium content
- D. Bake or grill the meat rather than frying it
Correct Answer: C
Rationale: The correct answer is C. Reading food labels to determine sodium content is important in managing mild hypernatremia. This allows the client to monitor and control their sodium intake, which can help prevent further elevation of sodium levels. Weighing oneself or checking the pulse does not directly address sodium intake. Choosing cooking methods like baking or grilling is more about reducing fat intake, not sodium.
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You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct Answer: C
Rationale: Correct Answer: C - Infiltration
Rationale:
1. Infiltration occurs when IV fluid leaks into surrounding tissues, causing edema.
2. Documenting infiltration is important for appropriate management.
3. Air emboli, phlebitis, and fluid overload are unrelated to edema around IV site.
Summary of Incorrect Choices:
A. Air emboli: This is a serious condition caused by air entering the bloodstream, not related to edema.
B. Phlebitis: Inflammation of the vein, usually presenting with redness and pain, not edema.
D. Fluid overload: Excess fluid volume in the body, leading to symptoms like shortness of breath, not edema.
You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You
and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your
colleague dismisses. What can this increase in creatinine indicate in older adults?
- A. Substantially reduced renal function
- B. Acute kidney injury
- C. Decreased cardiac output
- D. ) Alterations in ratio of body fluids to muscle mass
Correct Answer: A
Rationale: The correct answer is A: Substantially reduced renal function. In older adults, elevated serum creatinine levels can indicate impaired kidney function, as the kidneys may not filter waste products as efficiently. This can lead to a buildup of creatinine in the blood. Acute kidney injury (Choice B) is a sudden decline in kidney function and would typically present with a more significant increase in creatinine levels. Decreased cardiac output (Choice C) would not directly cause elevated creatinine levels. Alterations in the ratio of body fluids to muscle mass (Choice D) would not be a common cause of elevated creatinine levels in this scenario.
A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)
- A. Use a draw sheet to reposition the client in bed.
- B. . Strain all urine output and assess for urinary stones.
- C. Provide nonslip footwear for the client to use when out of bed.
Correct Answer: B
Rationale: The correct answer is B. Straining all urine output and assessing for urinary stones is important for a client with hypocalcemia as they are at risk for developing kidney stones due to increased calcium excretion. By straining urine, the nurse can monitor for the presence of stones.
A, using a draw sheet to reposition the client, is not directly related to hypocalcemia. C, providing nonslip footwear, is important for fall prevention but not specific to hypocalcemia. D, since it is not provided, cannot be evaluated.
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)
- A. Increased pulse rate
- B. . Distended neck veins
- C. Warm and pink skin
- D. Skeletal muscle weakness
Correct Answer: C
Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation.
Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload.
Step 3: Therefore, the correct answer is C.
Summary:
A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart.
B: Distended neck veins - Common in fluid overload due to increased venous pressure.
C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy.
D: Skeletal muscle weakness - Not directly related to fluid overload.
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
- A. Urine output of 25 mL/hr
- B. Serum potassium level of 5.4 mEq/L
- C. Blood osmolality of 250 mOsm/L
Correct Answer: A
Rationale: Step-by-step rationale for why option A is correct:
1. Inhibition of aldosterone secretion leads to decreased sodium reabsorption and increased water excretion.
2. Decreased aldosterone can result in decreased blood volume and BP, leading to decreased urine output.
3. Monitoring urine output is crucial to assess renal function and fluid balance.
4. A urine output of 25 mL/hr is considered inadequate and can indicate renal impairment or dehydration.
Summary:
Option A is correct as it directly relates to the mechanism of action of inhibiting aldosterone secretion. Options B, C, and D are incorrect as they do not align with the expected complications of aldosterone inhibition.