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).
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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Related Questions
Correct Answer is C
Explanation
A. Respiratory alkalosis: Respiratory alkalosis is more commonly associated with hyperventilation and is not directly linked to the physiological effects of a tension pneumothorax, where the primary concern is intrathoracic pressure changes.
B. Increased venous return: In tension pneumothorax, intrathoracic pressure increases significantly, compressing the great vessels and the heart, leading to decreased venous return, not an increase.
C. Decreased cardiac output: Tension pneumothorax causes a rise in intrathoracic pressure, which compresses the heart and great vessels, leading to decreased venous return and, consequently, reduced cardiac output. This is a critical finding and requires immediate intervention.
D. Dilated ventricles: Ventricular dilation is generally associated with chronic heart conditions, not acute issues like tension pneumothorax, where decreased filling pressures are more of a concern than dilation.
Correct Answer is B
Explanation
A. Respiratory acidosis occurs due to hypoventilation, resulting in carbon dioxide retention. This condition is characterized by slow, shallow breathing and confusion, which is not consistent with the client's rapid respiratory rate of 30/min.
B. Respiratory alkalosis is typically caused by hyperventilation, where excessive breathing leads to a decrease in carbon dioxide levels. The client's symptoms of high anxiety and rapid, shallow respirations are indicative of hyperventilation, making respiratory alkalosis the most likely diagnosis.
C. Metabolic acidosis is characterized by deep, rapid breathing (Kussmaul respirations) as the body attempts to expel excess acid. The client's shallow respirations are inconsistent with the breathing pattern seen in metabolic acidosis.
D. Metabolic alkalosis usually presents with symptoms such as dizziness and tingling, often with compensatory slow respirations. The rapid respiratory rate in this case does not suggest metabolic alkalosis, making this option unlikely.
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