A nurse is caring for a client who is receiving 0.45% sodium chloride. Which of the following actions should the nurse take?

Monitor for hypernatremia.

Assess for fluid overload.

Check for hypoglycemia.

Evaluate for dehydration.

Answer and Explanation

The Correct Answer is B

Choice A reason: Hypernatremia is unlikely with 0.45% sodium chloride, a hypotonic solution that dilutes serum sodium. Over-infusion risks hyponatremia, not high sodium levels. Monitoring for hypernatremia is inappropriate, as the solution’s low sodium content does not contribute to elevated sodium in fluid therapy.
Choice B reason: Assessing for fluid overload is essential, as 0.45% sodium chloride, being hypotonic, can cause water to shift into cells, risking pulmonary or cerebral edema. This is critical in clients with renal or cardiac issues, where monitoring for dyspnea or swelling ensures safe fluid administration.
Choice C reason: Hypoglycemia is not directly linked to 0.45% sodium chloride, which affects fluid and electrolytes, not glucose. Fluid shifts may indirectly stress metabolism, but hypoglycemia relates to fasting or insulin issues, making this an inappropriate focus for monitoring in this fluid therapy context.
Choice D reason: Dehydration is unlikely, as 0.45% sodium chloride provides free water, promoting hydration. It corrects hypernatremia or replaces fluid losses. Evaluating for dehydration is unnecessary unless infusion is inadequate or losses persist, which is not indicated in the context of this hypotonic solution.

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Correct Answer is B

Explanation

Choice A reason: Cardiogenic shock involves reduced cardiac output, typically with low PAWP due to decreased preload from poor heart function. Elevated PAWP reflects left atrial pressure buildup, not characteristic of cardiogenic shock alone, which is distinct from heart failure, requiring specific hemodynamic management.
Choice B reason: Elevated PAWP indicates left ventricular failure, where the heart cannot pump blood effectively, causing pulmonary congestion. This increases left atrial pressure, leading to pulmonary edema, a hallmark of heart failure. Diuretics and inotropes are needed to reduce fluid overload and improve cardiac function.
Choice C reason: Hypotension is a symptom, not a direct complication of elevated PAWP. It may occur in heart failure due to reduced cardiac output, but elevated PAWP specifically signals left heart dysfunction, not hypotension itself, which is a systemic response rather than a primary cardiac issue.
Choice D reason: Hypovolemia reduces blood volume, lowering PAWP due to decreased preload. Elevated PAWP suggests fluid overload or left ventricular dysfunction, not hypovolemia, which presents with low central venous pressure and dehydration signs, requiring fluid resuscitation rather than management of heart failure.

A. Place the client upright on a donut-shaped cushion. B. Turn and reposition the client every 15 minutes while sitting. C. Apply a moisture-barrier cream to the affected area. D. Turn and reposition the client every 3 hours while in bed.

Correct Answer is B

Explanation

Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.

Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.

Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.

Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.

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A nurse is caring for a client who is receiving 0.45% sodium chloride. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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