A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

Provide the client with additional oral fluids of her preference.

Measure the client's capillary glucose reading at regular intervals.

Encourage the client to use hard candy frequently to help relieve thirst.

Withhold the next diuretic dose until contacting the healthcare provider.

Answer and Explanation

The Correct Answer is C

Choice A reason: Providing additional oral fluids is not appropriate for SIADH and can worsen fluid retention.

Choice B reason: Measuring glucose levels is important for diabetes management but not directly related to SIADH.

Choice C reason: Offering hard candy stimulates saliva production and soothes oral mucosa, providing relief of dry mouth and the perception of thirst without adding significant fluid volume, thereby supporting strict fluid restriction in SIADH management.

Choice D reason:

Withholding a prescribed diuretic without a clear order can disrupt the therapeutic plan, exacerbate fluid retention, and falls outside the nurse’s scope; diuretic adjustments should only follow provider directions.

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Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because a bounding pulse, hypertension, and distended neck veins are signs of fluid overload, which can occur during blood transfusions, especially in older adults.

Choice B reason: A thready pulse, hypotension, and chest or back pain are more indicative of shock or severe anemia rather than fluid overload.

Choice C reason: Urticaria, itching, and wheezing suggest an allergic reaction, not fluid overload.

Choice D reason: Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but are not specific to fluid overload.

A. Keep room temperature cool. B. Determine the client's food preferences. C. Maintain a patent intravenous site. D. Teach the client relaxation techniques.

Correct Answer is C

Explanation

Choice A reason: Keeping the room temperature cool may help with comfort but is not the immediate priority.

Choice B reason: Determining the client's food preferences is important for nutritional management but is not the first action to take.

Choice C reason:

The correct answer is c) because maintaining a patent intravenous site is crucial for administering fluids and medications to address severe dehydration and malnutrition.

Choice D reason: Teaching relaxation techniques can help with restlessness but is not the most immediate concern.

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A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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