A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids?

The client has developed confusion.

The client's serum sodium is 140 mEq/L (135 to 145 mEq/L).

The client has a positive Chvostek's sign.

The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL).

Answer and Explanation

The Correct Answer is A

A. The client has developed confusion: Hypotonic fluids can cause a rapid shift of water into cells, potentially leading to cerebral edema. This can manifest as confusion or altered mental status, which is a serious adverse effect requiring immediate attention.

B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L): A serum sodium level within the normal range indicates that the hypotonic fluid therapy is likely effective in correcting hypernatremia, and does not suggest an adverse effect.

C. The client has a positive Chvostek's sign: A positive Chvostek's sign is indicative of hypocalcemia rather than an adverse effect of hypotonic fluid administration. This sign is related to low calcium levels and is not a direct result of hypotonic fluid therapy.

D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL): This BUN level is within normal limits and does not suggest an adverse effect of hypotonic fluid therapy. BUN levels can be affected by various factors, but this value alone is not indicative of an adverse reaction.

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Correct Answer is C

Explanation

A. Avoid vitamin supplements during therapy: This is not generally advised for isoniazid therapy. In fact, vitamin B6 supplements are often recommended to prevent peripheral neuropathy caused by isoniazid.

B. Drink alcohol in small amounts only: Alcohol can increase the risk of liver toxicity when taking isoniazid. It is typically advised to avoid alcohol altogether during treatment.

C. Report yellow eyes or skin immediately: Isoniazid can cause liver toxicity, which can lead to jaundice (yellowing of the eyes and skin). This is a serious side effect and should be reported immediately to prevent further liver damage.

D. Increase intake of Swiss or aged cheeses: This recommendation is not related to isoniazid therapy. Aged cheeses are more relevant to patients on monoamine oxidase inhibitors (MAOIs) due to tyramine content.

A. Repeat blood serum potassium B. Educate client regarding high-potassium food sources C. Cardiac monitoring during infusion D. Ensure that the client's urine output is at least 1 mL/kg/hour E. Ensure potassium infusion is prepared with 5% dextrose solution

Correct Answer is ["C","D"]

Explanation

A. Repeat blood serum potassium: While it’s important to monitor potassium levels, the immediate priority when preparing to administer potassium is ensuring safe administration practices, not rechecking levels before initiating therapy.

B. Educate client regarding high-potassium food sources: Client education is important for long-term management but is not a priority when preparing for intravenous potassium replacement in an acute setting.

C. Cardiac monitoring during infusion: Potassium affects cardiac conduction, and rapid correction can lead to arrhythmias. Continuous cardiac monitoring is necessary to detect any life-threatening arrhythmias during the infusion.

D. Ensure that the client's urine output is at least 1 mL/kg/hour: Adequate urine output ensures that the kidneys are functioning and capable of excreting excess potassium, reducing the risk of hyperkalemia.

E. Ensure potassium infusion is prepared with 5% dextrose solution: Potassium should not be mixed with dextrose, as it can increase insulin release, causing potassium to shift into cells and worsen hypokalemia.

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A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids?

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Naxlex Comprehensive Predictor Exams

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to provide which information to the client?

Correct Answer is C

Explanation

A nurse is assisting with preparations for administering intravenous potassium replacement supplements to a client who has a potassium level of 2.5 mEq/L. Which of the following actions should the nurse plan to include? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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