A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?
Measure ankle circumference.
Obtain serum creatinine levels daily.
Ensure client takes a diuretic every morning.
Monitor daily sodium intake.
The Correct Answer is C
Rationale
A. This intervention is important for assessing peripheral edema, which can indicate fluid overload. While relevant, it is not the highest priority in addressing acute weight gain and elevated blood pressure.
B. Daily monitoring of serum creatinine is important but is more relevant once diuretic therapy is initiated to assess renal function and electrolyte balance.
C. This option is crucial because diuretic therapy is aimed at correcting fluid imbalance in SIADH. However, the timing and dosage of diuretics should be adjusted based on clinical assessment and not solely on a fixed morning administration.
D. Monitoring sodium intake is a long-term strategy in managing SIADH to prevent hyponatremia. While important, it does not address the immediate concerns of fluid overload and elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Rationale
A. High in sodium due to pickling, which is not suitable for someone with hypertension.
B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.
C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.
D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.
E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.
Correct Answer is ["0.75"]
Explanation
Calculate the volume of the reconstituted solution that contains the prescribed dose of 0.1875 mg. Since the reconstituted solution has a concentration of 0.25 mg per 1 mL, we can set up a proportion to find the answer: (0.1875 mg / X mL) = (0.25 mg / 1 mL).
Solving for X gives us X = (0.1875 mg * 1 mL) / 0.25 mg, which equals 0.75 mL.
Therefore, the nurse should administer 0.75 mL of the reconstituted solution.
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