A 65-year-old female presents with confusion, headache, and muscle weakness. Her sodium level is 120 mEq/L. Which of the following interventions is most appropriate based on her condition?

Administer hypertonic saline and restrict water intake

Start fluid restriction and administer a loop diuretic

Administer isotonic saline and encourage oral fluid intake

Increase oral sodium intake and administer an antiemetic

Answer and Explanation

The Correct Answer is A

A. Administering hypertonic saline (3% NaCl) is appropriate for treating severe hyponatremia, as it helps to raise sodium levels safely. Restricting water intake is also necessary to prevent further dilution of sodium.
B. Fluid restriction with a loop diuretic may not be effective in this scenario and can worsen the hyponatremia by causing further fluid loss without addressing the sodium levels.
C. Isotonic saline is not indicated for correcting severe hyponatremia, and encouraging oral fluid intake could exacerbate the condition.
D. Increasing oral sodium intake is not sufficient for immediate correction of severe hyponatremia and does not address the acute nature of the client’s symptoms.

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Correct Answer is B

Explanation

A. Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not evident in this scenario where the pH is low and PaCO2 is elevated.
B. The low pH of 7.3 indicates acidemia, and the elevated PaCO2 of 50 mm Hg suggests respiratory acidosis, where the body is retaining carbon dioxide, leading to an increase in acidity.
C. Metabolic acidosis would present with a low pH and a normal or decreased PaCO2, which is not the case here since the PaCO2 is elevated.
D. Metabolic alkalosis would show a high pH and elevated HCO3 levels, which is not consistent with the given ABG results.

A. Mottled skin B. Heart rate 160/min C. Blood pressure 115/68 mmHg D. Hypokalemia

Correct Answer is C

Explanation

A. Mottled skin is more indicative of the progressive or refractory stages of shock, where perfusion to the skin is severely compromised.
B. A heart rate of 160/min indicates tachycardia, which is common in shock but is not the most characteristic finding of the compensatory stage.
C. During the compensatory stage of shock, the body attempts to maintain blood pressure and perfusion, and a blood pressure of 115/68 mmHg suggests that compensatory mechanisms are still functioning adequately.
D. Hypokalemia is not a typical finding in the compensatory stage; rather, the body may exhibit signs of hyperkalemia due to tissue breakdown and acidosis.

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A 65-year-old female presents with confusion, headache, and muscle weakness. Her sodium level is 120 mEq/L. Which of the following interventions is most appropriate based on her condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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