A 49-year-old female patient receives 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

Peripheral pulses

Urinary output

Peripheral edema

Lung sounds and neurological status

Answer and Explanation

The Correct Answer is D

Choice A: Peripheral pulses
Monitoring peripheral pulses is important for assessing circulation and detecting any signs of vascular complications. However, it is not the most critical assessment for a patient receiving 3% NaCl for hyponatremia. The primary concern with hypertonic saline infusion is the risk of fluid overload and central nervous system (CNS) complications.
Choice B: Urinary output
Monitoring urinary output is essential for assessing kidney function and fluid balance. While it is important, it is not the most critical assessment in this scenario. The primary risks associated with 3% NaCl infusion include rapid changes in serum sodium levels and potential CNS complications.
Choice C: Peripheral edema
Peripheral edema can indicate fluid overload, but it is not the most immediate concern when administering hypertonic saline. The nurse should prioritize monitoring for signs of pulmonary edema and neurological changes, which can occur more rapidly and have more severe consequences.
Choice D: Lung sounds and neurological status
Monitoring lung sounds and neurological status is the most important assessment for a patient receiving 3% NaCl for hyponatremia. Hypertonic saline can cause rapid shifts in fluid balance, leading to pulmonary edema and neurological complications such as osmotic demyelination syndrome. Assessing lung sounds helps detect early signs of fluid overload in the lungs, while monitoring neurological status helps identify any changes in mental status or neurological function that could indicate serious complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Notifying the oncologist or healthcare provider immediately is crucial in the event of a reaction or side effect during chemotherapy. Prompt communication with the healthcare provider ensures that the patient receives appropriate and timely medical intervention. The oncologist can provide specific instructions on managing the reaction, including any necessary medications or adjustments to the chemotherapy regimen. Immediate notification helps in preventing the escalation of the reaction and ensures patient safety.

Choice B reason:

Slowing the chemotherapy infusion is not typically recommended as an immediate intervention for a severe reaction. While adjusting the infusion rate can be considered for mild reactions, it is not sufficient for managing more serious side effects or hypersensitivity reactions. In cases of significant reactions, stopping the infusion and taking other emergency measures are more appropriate. Slowing the infusion might delay the necessary interventions and could potentially worsen the patient’s condition.

Choice C reason:

Stopping the chemotherapy infusion is a critical step in managing a reaction. Halting the infusion immediately prevents further exposure to the causative agent, which can help in stabilizing the patient’s condition. This action is essential to prevent the reaction from worsening and allows time for the healthcare team to assess the situation and implement appropriate interventions. Stopping the infusion is a standard protocol in managing infusion-related reactions.

Choice D reason:

Assessing Ms. Anderson’s vital signs and symptoms is essential to determine the severity of the reaction and guide further interventions. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation provides crucial information about the patient’s physiological status. This assessment helps in identifying any life-threatening changes and ensures that appropriate measures are taken to stabilize the patient. Continuous monitoring is vital for detecting any deterioration in the patient’s condition.

Choice E reason:

Infusing normal saline at 100 ml/hr is an important intervention to maintain intravenous access and provide fluid support. Normal saline helps in stabilizing the patient’s blood pressure and improving circulation, which can be compromised during a severe reaction. It also ensures that the IV line remains patent for the administration of emergency medications if needed. Fluid support is a key component of managing infusion-related reactions and preventing complications.

A. Operative site B. Airway C. Pulse D. Skin integrity

Correct Answer is B

Explanation

Choice A reason:
Assessing the operative site is important to monitor for signs of bleeding, infection, or other complications. However, it is not the most critical, high-priority assessment immediately after surgery. While the condition of the surgical site can provide valuable information about the patient’s recovery and potential complications, it does not take precedence over ensuring the patient’s airway is clear and they are breathing adequately. The operative site can be assessed once the patient’s airway, breathing, and circulation are stable.
Choice B reason:
Airway assessment is the most critical, high-priority assessment in the PACU. Ensuring that the patient’s airway is clear and they are breathing properly is paramount because anesthesia can depress the central nervous system, leading to compromised airway patency and respiratory function. The primary goal in the immediate postoperative period is to ensure that the patient is ventilating adequately to prevent hypoxia and other respiratory complications. This involves checking for airway obstruction, monitoring respiratory rate, and ensuring that oxygen saturation levels are within normal ranges (typically 95-100% for healthy individuals). Any issues with the airway must be addressed immediately to prevent life-threatening complications.
Choice C reason:
Assessing the pulse is crucial for monitoring the patient’s cardiovascular status, including heart rate and rhythm. This can help detect arrhythmias, hypovolemia, or other cardiovascular issues that may arise postoperatively. However, while important, it is secondary to ensuring that the patient’s airway is clear and they are breathing adequately. The pulse can be assessed once the airway and breathing are confirmed to be stable. Normal pulse rates for adults typically range from 60 to 100 beats per minute.
Choice D reason:
Assessing skin integrity is important for identifying signs of pressure ulcers, infection, or other skin-related issues. However, this assessment is not the highest priority immediately after surgery. Ensuring the patient’s airway, breathing, and circulation are stable takes precedence. Skin integrity can be assessed once the patient is stable and other critical assessments have been completed. Maintaining skin integrity is essential for overall patient care, but it does not supersede the need to ensure the patient is breathing properly and has a clear airway.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 49-year-old female patient receives 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The next 3 questions relate to this case study: Exhibits In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The following 4 questions pertain to this case study: Exhibits In PACU, many assessments and interventions are done simultaneously. However, the most critical, high-priority assessment is:

Correct Answer is B

Explanation

Select four principles of aseptic technique in the operating room from the list provided.

The essential core of nursing practice is to deliver holistic, patient-centered care. This includes assessment and evaluation, providing a variety of interventions, patient and caregiver teaching, and being a member of the interprofessional healthcare team.

Exhibits Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

The following 4 questions pertain to this case study: Exhibits Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?

Which statement best describes the nurse’s role in medication reconciliation?

A heating pad is ordered for a patient with a lumbar sprain. The nurse knows that the purpose of the heating pad is to:

Which six factors should the nurse consider when choosing a time frame for reassessing the patient’s pain level after implementing pain management?

A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?