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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale

A. Informing the information services department allows them to be aware of the issue promptly. They can then investigate the cause of the system failure and initiate appropriate measures to restore the system. It's important to involve IT professionals who are responsible for maintaining and troubleshooting the computer system.

B. While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.

C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.

D. Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.

A. Clenched fists. B. Increased temperature. C. Restlessness. D. Peripheral pallor of the skin. E. E Increased respiratory rate. F. Increased pulse rate.

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

Explanation

Rationale

A. Clenched fists can be a sign of pain in infants. Infants may reflexively clench their fists as a response to discomfort or pain. This behavior is commonly observed during painful procedures or when experiencing pain.

B. While fever can sometimes accompany pain due to inflammation or stress response, it is not typically a reliable indicator of pain in the absence of other signs. Therefore, fever alone is not a specific indicator of pain post-pyloromyotomy.

C. Restlessness or increased agitation can indicate pain in infants. They may squirm, move their arms and legs, or have difficulty settling down. Restlessness is a non-verbal cue that infants use to communicate discomfort or distress.

D. Peripheral pallor could indicate decreased peripheral perfusion, which might occur due to various factors post-operatively, but it is not a direct indicator of pain.

E. Increased respiratory rate can be associated with pain.

F. An increased pulse rate (tachycardia) is a physiological response to pain in infants. Pain activates the sympathetic nervous system, leading to an increased heart rate as the body prepares to respond to stress or discomfort.

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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?

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Naxlex Comprehensive Predictor Exams

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

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

Explanation

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