A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following actions should the nurse take?
Restrict oral fluids to 800 to 1,000 mL/day.
Maintain an IV of 0.45% sodium chloride.
Ensure the client receives a 2 g/day sodium diet.
Administer desmopressin acetate 0.2 mg orally.
The Correct Answer is A
a. Restrict oral fluids to 800 to 1,000 mL/day: Hyponatremia is a characteristic finding in SIADH, and fluid restriction is a key intervention to correct the imbalance.
b. Maintain an IV of 0.45% sodium chloride: Infusing hypertonic (3%) saline may be indicated in severe cases of hyponatremia, but the initial step is fluid restriction.
c. Ensure the client receives a 2 g/day sodium diet: Dietary sodium restriction is not the primary intervention for SIADH. Fluid restriction is more critical.
d. Administer desmopressin acetate 0.2 mg orally: Desmopressin acetate is an antidiuretic
hormone and would exacerbate the retention of water, further decreasing sodium levels. It is not the appropriate intervention for this client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between
inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.
b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.
c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.
d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.
Correct Answer is A
Explanation
a. “Managing my cholesterol will reduce my chances of having a stroke.”: High cholesterol is a risk factor for stroke, and managing it can help reduce the risk.
b. “My blood pressure needs to stay a little elevated for good blood flow to my brain.”:
Maintaining normal blood pressure is essential for preventing stroke, and elevated blood pressure is a risk factor for stroke.
c. “Using oral contraceptives provides me with protection from a stroke.”: Oral contraceptives, especially in the presence of other risk factors, can increase the risk of stroke.
d. “I can safely have up to 3 alcoholic drinks a day.”: Excessive alcohol consumption is a risk factor for stroke, and moderation is advised to reduce the risk.
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