Nokea
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
You may also like to solve these questions
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate?
- A. Collect a clean voided midstream urine specimen.
- B. Evaluate the client’s eight (8)-hour intake and output.
- C. Assist in checking a unit of blood prior to hanging.
- D. Administer a cation-exchange resin enema.
Correct Answer: A
Rationale: Collecting a clean voided midstream urine specimen is a task within the UAP’s scope, as it involves following a standard procedure. Evaluating intake/output, checking blood, or administering enemas require nursing judgment or specialized training, making them inappropriate for delegation.
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.
Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?
- A. Place the client in the Trendelenburg position.
- B. Turn off the dialysis machine immediately.
- C. Bolus the client with 500 mL of normal saline.
- D. Notify the health-care provider as soon as possible.
Correct Answer: B
Rationale: Dizziness and light-headedness during dialysis suggest hypotension, often due to rapid fluid removal. Turning off the dialysis machine stops fluid removal, stabilizing the client. Trendelenburg, saline bolus, or notifying the provider are secondary actions.
When preparing the client for catheterization, how should the nurse position the client?
- A. Lithotomy position
- B. Recumbent
- C. Knee-chest position
- D. Prone
Correct Answer: A
Rationale: The lithotomy position provides optimal access to the urethral meatus for catheterization in female clients.