A nurse is assessing a client who has received treatment for hypernatremia. Which of the following findings indicates the treatment has been effective?
Firm grip bilaterally
Fatigue
2+ deep tendon reflexes
Urine output 25 mL/hr
The Correct Answer is C
Choice A reason: A firm bilateral hand grip indicates normal muscle strength, which is a positive sign but not directly related to hypernatremia treatment efficacy.
Choice B reason: Fatigue is not a sign of effective treatment for hypernatremia. Fatigue can be a symptom of hypernatremia, as well as dehydration, infection, or other conditions. The nurse should assess the client for other causes of fatigue and monitor their vital signs and fluid status.
Choice C reason: Deep tendon reflexes graded as 2+ are considered normal and suggest that neuromuscular function is intact. Since hypernatremia can cause neuromuscular excitability, normal reflexes may indicate effective treatment.
Choice D reason: Urine output 25 mL/hr is not a sign of effective treatment for hypernatremia. Urine output 25 mL/hr is below the normal range of 30 to 50 mL/hr and indicates oliguria, which can be a complication of hypernatremia. Oliguria can result from dehydration, kidney damage, or reduced blood flow to the kidneys due to hypernatremia. The nurse should notify the provider and administer fluids as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Decreased fat intake is not a barrier to wound healing, as long as the client meets the recommended daily intake of essential fatty acids. Fat is important for cell membrane integrity, inflammation, and immune function. However, excessive fat intake can increase the risk of obesity, diabetes, and cardiovascular disease, which can impair wound healing.
Choice B reason: Decreased vitamin C intake is a barrier to wound healing, as vitamin C is essential for collagen synthesis, wound repair, and antioxidant activity. Vitamin C deficiency can lead to impaired wound healing, increased susceptibility to infection, and scurvy. The nurse should encourage the client to consume foods rich in vitamin C, such as citrus fruits, berries, peppers, broccoli, and tomatoes.
Choice C reason: Increased protein intake is not a barrier to wound healing, but rather a facilitator of wound healing, as protein is necessary for tissue growth, repair, and maintenance. Protein deficiency can result in delayed wound healing, increased risk of infection, and loss of lean body mass. The nurse should advise the client to consume adequate amounts of high-quality protein, such as eggs, milk, cheese, meat, fish, poultry, soy, and nuts.
Choice D reason: Increased caloric intake is not a barrier to wound healing, but rather a facilitator of wound healing, as calories provide energy for wound healing processes. Caloric deficiency can lead to malnutrition, weight loss, and impaired wound healing. The nurse should ensure that the client meets their caloric needs based on their age, weight, activity level, and wound severity.
Correct Answer is D
Explanation
Choice A reason: Abdominal distention is a possible complication of enteral nutrition, as it may indicate gas accumulation, constipation, or intolerance to the formula. However, it is not the greatest risk to the client, as it can be prevented or managed by adjusting the formula, rate, or volume of the feeding, or by administering medications or enemas.
Choice B reason: Fluid overload is a possible complication of enteral nutrition, as it may indicate excessive fluid intake, renal impairment, or heart failure. However, it is not the greatest risk to the client, as it can be prevented or managed by monitoring the fluid balance, electrolytes, and vital signs, or by administering diuretics or fluid restriction.
Choice C reason: Glycosuria is a possible complication of enteral nutrition, as it may indicate hyperglycemia, diabetes, or infection. However, it is not the greatest risk to the client, as it can be prevented or managed by monitoring the blood glucose, urine output, and signs of infection, or by administering insulin or antibiotics.
Choice D reason: Tube obstruction is the greatest risk to the client, as it may indicate clogging, kinking, or twisting of the tube, which can impair the delivery of the nutrition and medication, and cause aspiration, infection, or perforation. Tube obstruction can be prevented by flushing the tube with water before and after each feeding or medication, and by using a syringe or a pump to administer the formula. Tube obstruction can be managed by using warm water, carbonated beverages, or pancreatic enzymes to unclog the tube, or by replacing the tube if necessary.

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