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 C
Explanation
Choice A reason: Formula should not be changed to whole milk until the infant is 12 months old, as whole milk does not provide enough iron and other nutrients for the infant's growth and development. Whole milk can also cause intestinal bleeding and increase the risk of allergies in infants younger than 12 months.
Choice B reason: Formula that remains in the bottle should not be used for another feeding, as it can harbor bacteria and cause infection. Any formula that is not consumed within one hour of preparation or feeding should be discarded.
Choice C reason: If the infant turns away after taking most of the feeding, it is a sign that the infant is full and satisfied. The nurse should instruct the parents to stop the feeding and burp the infant. Forcing the infant to finish the bottle can cause overfeeding and vomiting.
Choice D reason: If the infant is gaining weight too rapidly, diluting the formula is not a safe or effective solution. Diluting the formula can cause water intoxication, electrolyte imbalance, and malnutrition in the infant. The nurse should advise the parents to consult with the infant's doctor about the appropriate amount and type of formula for the infant.
Correct Answer is B
Explanation
Choice A reason: Anticholinesterase medications should be taken 30 minutes before meals, not with meals. This is because they enhance the action of acetylcholine, which improves muscle strength and swallowing ability.
Choice B reason: Positioning the head of the client's bed to 40° while eating helps prevent aspiration and facilitates swallowing. This is the best action for the nurse to take for a client who has myasthenia gravis.
Choice C reason: Encouraging the client to lie down after eating is not advisable, as it increases the risk of aspiration and reflux. The client should remain upright for at least 30 minutes after eating.
Choice D reason: Providing the client with food cut into small bites is not enough to ensure safe and adequate nutrition. The client may still have difficulty swallowing and chewing. The nurse should also offer soft, moist, and easy-to-swallow foods, and avoid foods that are dry, sticky, or hard.
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