A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect?

Decreased bowel sounds

Increased central venous pressure

Confusion

Hyperreflexia

Answer and Explanation

The Correct Answer is C

A serum sodium level of 120 mEq/L indicates hyponatremia, which is a condition where there is an excess of water relative to sodium in the body fluids. Hyponatremia can cause various neurological symptoms such as confusion, lethargy, seizures, coma, and death.

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Correct Answer is A

Explanation

Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.

A. Check the IV site for redness. B. Ensure the tubing connections are secure. C. Reposition the client's left arm. D. Flush the IV catheter.

Correct Answer is C

Explanation

This is because the most common cause of infusion pump alarms is occlusion or obstruction of the IV line, which can be due to kinking, bending, or compression of the tubing or catheter by the client's arm or body position. By repositioning the client's arm, the nurse can relieve the occlusion and restore the flow of the IV fluid.

This action should be done before checking for other possible causes of alarm, such as redness at the IV site (which could indicate infection or inflammation), loose tubing connections (which could cause leakage or air embolism), or clogged IV catheter (which could require flushing with saline or heparin solution).

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A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect?

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