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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Asking for more information about the surgery indicates the client seeks clarification but does not confirm understanding of informed consent. Informed consent requires comprehension of the procedure, risks, benefits, and alternatives, with agreement to proceed. This statement reflects curiosity, not confirmation of understanding, making it insufficient to demonstrate informed consent.
Choice B reason: Planning to ask the doctor about the surgery in the operating room suggests the client has not yet received or understood the necessary information. Informed consent must be obtained before entering the operating room, with full comprehension of risks and benefits. This statement indicates a lack of prior understanding, making it incorrect.
Choice C reason: Stating understanding of the risks, benefits, and agreement to the procedure demonstrates informed consent. This reflects that the client has been educated about the knee arthroplasty, including potential complications like infection or blood clots, and alternatives, and voluntarily agrees to proceed. This meets legal and ethical standards, indicating full comprehension and consent.
Choice D reason: Having family sign the consent form is inappropriate unless the client lacks decision-making capacity, which is not indicated. Informed consent requires the competent client’s understanding and agreement. This statement suggests reliance on others, not personal comprehension of the procedure’s risks and benefits, making it an incorrect indicator of understanding.
Correct Answer is B
Explanation
Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.
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