A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution.
Which of the following findings should indicate to the nurse that the treatment is effective?

Improved cognition.

Cardiac arrhythmias absent.

Decreased vomiting.

Absent Chvostek’s sign.

Answer and Explanation

The Correct Answer is A

Hyponatremia is a condition where the sodium level in the blood is too low, which can cause confusion, lethargy, seizures, and coma. A hypertonic solution is a fluid that has a higher concentration of solutes than the blood, which can help raise the sodium level and reduce the brain swelling caused by hyponatremia. Therefore, improved cognition indicates that the treatment is effective.

Choice B. Cardiac arrhythmias absent.

Cardiac arrhythmias are not a common symptom of hyponatremia unless it is severe or rapid in onset.

Therefore, their absence does not necessarily indicate that the treatment is effective.

Choice C. Decreased vomiting.

Vomiting can be a cause or a consequence of hyponatremia, depending on the underlying condition.

Decreased vomiting may indicate that the patient is less nauseated, but it does not reflect the sodium level or the brain status.

Choice D. Absent Chvostek’s sign.

Chvostek’s sign is a facial twitching that occurs when tapping on the cheek, which indicates hypocalcemia (low calcium level).

It is not related to hyponatremia or hypertonic solution.

Normal ranges for sodium are 135 to 145 mEq/L and for calcium are 8.5 to 10.5 mg/dL.

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Correct Answer is D

Explanation

The client will need to have blood levels drawn to monitor the therapeutic and toxic levels of theophylline, a bronchodilator that is used to treat symptoms of asthma and other lung conditions. The normal range of theophylline in the blood is 10 to 20 mcg/mL.

Choice A is wrong because the client should not sprinkle the medication in applesauce or any other food. Theophylline is a sustained-release capsule that should be swallowed whole and not crushed or chewed.

Choice B is wrong because the client should avoid caffeine while on this medication, as it can increase the side effects of theophylline, such as nausea, vomiting, headache, and irregular heart rate.

Choice C is wrong because the client should not limit fluid intake while on this medication unless instructed by the doctor.

Fluid intake helps prevent dehydration and kidney problems that can affect theophylline levels in the blood.

A. Initiate a new IV distal to the initial site. B. Slow the IV solution rate. C. Maintain the extremity below the level of the heart. D. Apply a warm, moist compress.

Correct Answer is D

Explanation

The most appropriate action for the nurse to take in this situation is:

d. Apply a warm, moist compress.

Here's why the other options are not recommended:

a. Initiate a new IV distal to the initial site:This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
b. Slow the IV solution rate:Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
c. Maintain the extremity below the level of the heart:This action would actually worsen the edema by promoting fluid accumulation at the site.

Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:

Stop the IV infusion.
Assess the extent of the infiltration or extravasation.
Document the findings.
Elevate the affected extremity.
Consult with a physician for further instructions and potential treatment.

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A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective?

Nursing Test Bank

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A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution.
Which of the following findings should indicate to the nurse that the treatment is effective?