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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: True
Chemotherapy drugs work by targeting rapidly dividing cells, a characteristic of cancer cells. However, they cannot selectively distinguish between cancer cells and normal cells that also divide rapidly, such as those in the bone marrow, digestive tract, and hair follicles. This lack of selectivity leads to the common side effects of chemotherapy, such as hair loss, nausea, and decreased blood cell counts. The inability to differentiate between normal and cancer cells is a significant limitation of traditional chemotherapy.
Choice B: False
This choice is incorrect. If chemotherapy drugs could selectively target only cancer cells, the treatment would have fewer side effects and be more effective. However, the non-selective nature of these drugs means they also damage normal, healthy cells that divide rapidly. This non-selectivity is why patients undergoing chemotherapy often experience a range of side effects, as the treatment impacts both cancerous and healthy cells.
Correct Answer is ["B","C"]
Explanation
Choice A: Hyponatremia - Dehydration
Hyponatremia occurs when the sodium levels in the blood are abnormally low. While dehydration can contribute to hyponatremia, it is not the most common cause. Hyponatremia is more frequently caused by conditions that lead to an excess of water in the body, diluting the sodium levels. These conditions include heart failure, kidney disease, and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Choice B: Hypomagnesemia - Chronic alcoholism
This is a correct pairing. Hypomagnesemia, or low magnesium levels in the blood, is often associated with chronic alcoholism. Alcoholism can lead to poor dietary intake of magnesium, increased urinary excretion of magnesium, and gastrointestinal losses due to vomiting and diarrhea. These factors contribute to the development of hypomagnesemia in individuals with chronic alcoholism.
Choice C: Hyperkalemia - Kidney failure
This is also a correct pairing. Hyperkalemia, or high potassium levels in the blood, is commonly caused by kidney failure. The kidneys are responsible for excreting excess potassium from the body. When the kidneys are not functioning properly, they cannot remove potassium efficiently, leading to its accumulation in the blood. Other causes of hyperkalemia include certain medications, such as potassium-sparing diuretics, and conditions that cause cellular breakdown, such as rhabdomyolysis.
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