A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement?Reference Range:

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Assess for increasing fluid volume overload.

Withhold next scheduled dose of treatment.

Increase neurologic checks to every 2 hours.

Maintain the prescribed fluid restriction.

Answer and Explanation

The Correct Answer is D

A. Assessing for increasing fluid volume overload is not indicated with a rising serum sodium level; instead, it suggests correction of hyponatremia, a common complication of SIADH.

B. Withholding the next scheduled dose of treatment is not appropriate based solely on a rise in serum sodium level within the normal range.

C. Increasing neurologic checks may be necessary in severe cases of hyponatremia but is not directly indicated by a rise in serum sodium within the normal range.

D. Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.

B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.

C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.

D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.

A. Auscultate the abdomen for bowel sound activity. B. Bring additional sterile dressing supplies to the room. C. Obtain a sample of the drainage to send to the laboratory. D. Prepare the client to return to the operating room.

Correct Answer is D

Explanation

A. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.

B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.

C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.

D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?

Correct Answer is D

Explanation

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?