A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Encourage eating potassium-rich foods.

Restrict sodium in the diet

Decrease water intake

Monitor vital signs

Monitor intake and output.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale: Hypernatremia involves elevated sodium levels, so encouraging potassium-rich foods is not directly related to addressing hypernatremia.

Choice B rationale: Restricting sodium in the diet is appropriate to help manage and reduce hypernatremia. This can prevent further complications of hypernatremia, such as dehydration, confusion, seizures, and coma.

Choice C rationale: This is not an appropriate intervention for hypernatremia, as water intake can help dilute the sodium levels and restore the fluid balance in the body.

Decreasing water intake can worsen the hypernatremia and cause dehydration. Choice D rationale: This is an appropriate intervention for hypernatremia, as high sodium levels can affect the fluid balance and blood pressure in the body. Monitoring

vital signs can help detect any changes or abnormalities that may indicate worsening of the condition or need for further treatment.

Choice E rationale: Monitoring intake and output helps assess fluid balance and response to interventions for hypernatremia.

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Correct Answer is A

Explanation

Choice A rationale: Spreading the skin taut while inserting the needle can minimize discomfort by reducing the sensation of the needle puncturing the skin.

Choice B rationale: Applying heat to the area before the injection is not a common practice and may not significantly reduce discomfort during the injection.

Choice C rationale: Holding the barrel of the syringe still while injecting the medication is important for accuracy but does not specifically address minimizing discomfort.

Choice D rationale: Testing for blood return before injecting the medication is a technique used with intramuscular but it does not minimize pain during injection.

A. Injecting one mL of air into a vial before withdrawing 20 mg furosemide from a vial labeled 20 mg/mL B. Instructing a client to place a buccal medication under the client's tongue and allowing it to absorb. C. Pouring the ordered medication "Robitussin 2 tsp. now to the 10 ml mark on a medication cup. D. Selecting a 1 ml syringe with a 5/8 inch needle to be used for giving 0.5 mL of heparin subcutaneously.

Correct Answer is B

Explanation

Choice A rationale: Injecting one mL of air into a vial before withdrawing 20 mg furosemide is an appropriate technique to equalize pressure in the vial.

Choice B rationale: Instructing a client to place a buccal medication under the client's tongue this is a method for administering sublingual medications. Buccal medications are placed between the cheek and the gum and allowed to dissolve slowly.

Choice C rationale: Pouring liquid medication to the 10 ml mark on a medication cup is acceptable, as long as the cup is held at eye level and the lowest point of the meniscus is used to measure the volume.

Choice D rationale: Selecting a 1 ml syringe with a 5/8 inch needle is suitable for giving heparin subcutaneously, as this ensures accuracy and minimizes tissue trauma.

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A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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