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: Dry cough is not associated with sertraline, an SSRI affecting serotonin pathways. Cough is linked to ACE inhibitors via bradykinin accumulation, not SSRIs, which cause neurological or gastrointestinal side effects. Including this misinforms the client about sertraline’s actual adverse effect profile.
Choice B reason: Increased urinary frequency is not a common sertraline side effect. SSRIs may cause urinary retention due to anticholinergic effects, but frequent urination is linked to diuretics or diabetes. Sertraline’s effects focus on serotonin-mediated mood changes, not bladder function alterations.
Choice C reason: Excessive sweating is a recognized sertraline adverse effect, driven by serotonin’s influence on autonomic sweat gland regulation. This hyperhidrosis, common in SSRI therapy, affects patient comfort and adherence, requiring education to prepare clients for this side effect during depression treatment.
Choice D reason: Metallic taste is not linked to sertraline. It occurs with antibiotics or chemotherapy agents due to oral mucosa irritation. Sertraline’s side effects include nausea or insomnia, driven by serotonin modulation, not gustatory changes, making this an incorrect inclusion in teaching.
Correct Answer is D
Explanation
Choice A reason: Contractions lasting 60 seconds every 5 minutes are normal for active labor, indicating effective uterine activity to progress delivery. This does not require immediate reporting, as it aligns with expected labor patterns and does not indicate fetal or maternal distress, making it a non-urgent finding.
Choice B reason: A fetal heart rate of 140 beats per minute is within the normal range (110-160 bpm) for a fetus in labor. This indicates fetal well-being and does not require reporting unless accompanied by abnormal patterns like decelerations, making this finding normal and not urgent.
Choice C reason: A maternal blood pressure of 120/80 mmHg is normal and does not indicate distress or complications like preeclampsia. It does not require reporting, as it reflects stable maternal hemodynamics during labor, making this finding non-urgent compared to fetal heart rate abnormalities.
Choice D reason: Late decelerations in the FHR indicate uteroplacental insufficiency, reducing fetal oxygenation and risking hypoxia. This requires immediate reporting to the provider for interventions like position changes or oxygen administration to prevent fetal distress, making it the critical finding necessitating urgent action.
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