A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)
Restrict fluid intake
Monitor neurological status
Administer hypotonic IV fluids
Encourage foods high in sodium
Provide oral hygiene frequently
Correct Answer : B,C,E
Choice A reason:
Restricting fluid intake is not an action that the nurse should take for a client who has hypernatremia. Fluid restriction can worsen hypernatremia by increasing the concentration of sodium in the blood. Fluid intake should be increased or replaced with isotonic or hypotonic fluids to dilute sodium and correct hypernatremia.
Choice B reason:
Monitoring neurological status is an action that the nurse should take for a client who has hypernatremia. Hypernatremia can cause neurological symptoms such as confusion, agitation, seizures, coma, and death due to cellular dehydration and brain shrinkage. The nurse should assess the client's level of consciousness, orientation, memory, behavior, and reflexes regularly and report any changes or deterioration.
Choice C reason:
Administering hypotonic IV fluids is an action that the nurse should take for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than normal body fluids and can help lower serum sodium levels by moving water into the cells from the blood vessels. The nurse should administer hypotonic fluids slowly and carefully to avoid fluid overload or cerebral edema.
Choice D reason:
Encouraging foods high in sodium is not an action that the nurse should take for a client who has hypernat
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B reason:
Transparent film dressing is a type of dressing that consists of a thin sheet of polyurethane with an adhesive coating. It allows oxygen and moisture vapor to pass through but prevents bacteria and water from entering the wound. It is suitable for wounds with minimal drainage, such as superficial abrasions or donor sites.
Choice C reason:
Calcium alginate dressing is a type of dressing that consists of fibers derived from seaweed that form a gel-like substance when they come in contact with wound exudate. It absorbs large amounts of drainage and supports autolytic debridement of necrotic tissue. It is suitable for wounds with heavy drainage, such as pressure ulcers or venous ulcers.
Choice D reason:
Hydrogel dressing is a type of dressing that consists of water or glycerin-based gel that provides moisture to dry wounds and supports autolytic debridement of necrotic tissue. It is suitable for wounds with minimal to moderate drainage, such as partial-thickness burns or radiation injuries.
Correct Answer is C
Explanation
Choice A reason:
Bacteria are microorganisms that have a cell wall composed of peptidoglycan and a cell membrane composed of phospholipids. They can be classified by their shape (cocci or bacilli), their Gram stain (positive or negative), or their oxygen requirement (aerobic or anaerobic).
Choice B reason:
Viruses are microorganisms that have a nucleic acid core (DNA or RNA) surrounded by a protein coat (capsid) and sometimes an envelope derived from the host cell membrane. They can only replicate inside living cells and cause various diseases such as influenza, herpes, hepatitis, or AIDS.
Choice C reason:
Fungi are microorganisms that have a cell wall composed of chitin and a cell membrane composed of ergosterol. They can exist as yeasts or molds depending on the environmental conditions. Candida albicans is an example of fungi that can cause infections such as thrush, vaginitis, or systemic candidiasis.
Choice D reason:
Parasites are microorganisms that live on or in another organism (host) and derive nutrients from it. They can be classified by their size (protozoa or helminths) or their mode of transmission (vector-borne or direct contact). They can cause infections such as malaria, giardiasis, or schistosomiasis.
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