Nokea
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory result requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum potassium of 4.5 mEq/L.
- C. Serum osmolality of 280 mOsm/kg.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Serum sodium of 130 mEq/L. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia. A serum sodium level of 130 mEq/L indicates severe hyponatremia, which can result in neurological symptoms, such as confusion, seizures, and coma. Therefore, immediate intervention is required to prevent further complications. Choice A, a serum sodium of 140 mEq/L, is within the normal range and does not require immediate intervention. Choice B, serum potassium of 4.5 mEq/L, is also within the normal range and is not directly related to SIADH. Choice C, serum osmolality of 280 mOsm/kg, is a measure of the concentration of solutes in the blood and may not be the most critical parameter to address in a client with SIADH and severe hyponatremia.
You may also like to solve these questions
The healthcare provider is assessing a client who has a new arteriovenous fistula in the left arm for hemodialysis. Which finding requires immediate intervention?
- A. A thrill is palpable on the fistula.
- B. The client's arm is warm and red.
- C. The fistula has a bruit on auscultation.
- D. There is no bruit on auscultation.
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness in the client's arm suggest infection or thrombosis of the arteriovenous fistula, which requires immediate intervention to prevent complications. A thrill (A) is a normal finding in a functional arteriovenous fistula, indicating good blood flow. A bruit (C) is also a normal finding on auscultation of a functioning arteriovenous fistula, indicating proper blood flow. The absence of a bruit (D) may indicate a non-functioning fistula, which would need further evaluation but does not require immediate intervention as warmth and redness do.
The nurse is caring for a client with cirrhosis of the liver. Which laboratory result requires immediate intervention?
- A. Serum albumin of 3.5 g/dL.
- B. Prothrombin time (PT) of 12 seconds.
- C. Hemoglobin of 10 g/dL.
- D. Serum ammonia level of 180 mcg/dL.
Correct Answer: D
Rationale: The correct answer is D, the serum ammonia level of 180 mcg/dL. An elevated serum ammonia level indicates hepatic dysfunction and can lead to hepatic encephalopathy, which is a medical emergency requiring immediate intervention. Options A, B, and C are within normal ranges or slightly abnormal values for clients with cirrhosis and do not pose an immediate threat. Serum albumin levels may indicate malnutrition, prothrombin time may reflect liver synthetic function, and hemoglobin levels can be affected by various factors but do not require immediate intervention in this scenario.
The nurse is preparing a teaching plan for a client who is newly diagnosed with hypothyroidism. Which instruction should the nurse include?
- A. Take levothyroxine (Synthroid) at bedtime.
- B. Increase fiber intake to prevent constipation.
- C. Take the medication on an empty stomach.
- D. Take a double dose if a dose is missed.
Correct Answer: C
Rationale: The correct instruction for a client newly diagnosed with hypothyroidism is to take the medication on an empty stomach. This is important because taking levothyroxine on an empty stomach ensures better absorption of the medication. Choice A, taking levothyroxine at bedtime, is incorrect as it does not promote optimal absorption. Choice B, increasing fiber intake to prevent constipation, is important but not the priority when it comes to medication administration. Choice D, taking a double dose if a dose is missed, is dangerous and should never be advised as it can lead to overdose and serious side effects.
In a community clinic where a recent case of tuberculosis (TB) has been diagnosed, which client who attended the clinic is at the highest risk for presenting with TB?
- A. a young adult who works as a daycare worker
- B. an adult who works in a corporate office
- C. an adolescent who attends the community high school
- D. an adult with a history of alcoholism and homelessness
Correct Answer: D
Rationale: Individuals who are homeless and have a history of alcoholism are at the highest risk for presenting with TB in this scenario. Homeless individuals often live in crowded conditions with poor ventilation, increasing the likelihood of TB transmission. Additionally, alcoholism can weaken the immune system, making individuals more susceptible to developing TB. The other options, such as a daycare worker, an office worker, or a high school student, do not inherently carry the same level of risk factors for TB transmission as being homeless with a history of alcoholism.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client is able to expectorate secretions easily.
- B. The client's oxygen saturation is 92%.
- C. The client's respiratory rate is 20 breaths per minute.
- D. The client's arterial blood gases show a pH of 7.35.
Correct Answer: C
Rationale: In a client with COPD receiving oxygen therapy, an effective response is indicated by a respiratory rate of 20 breaths per minute. This suggests that the client is effectively oxygenating while maintaining an appropriate respiratory rate. Choices A, B, and D are incorrect because expectorating secretions easily, having an oxygen saturation of 92%, and arterial blood gases showing a pH of 7.35 are not specific indicators of the effectiveness of oxygen therapy in COPD. Oxygen saturation of 92% may still be suboptimal in COPD, and arterial blood gases showing a pH of 7.35 may not necessarily reflect the overall effectiveness of oxygen therapy.