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 A

Explanation

Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.

A. Restrict fluids to 1,200 mL per day. B. Encourage deep breathing exercises every 2 hours. C. Apply a warm compress to the surgical site. D. Limit ambulation for 48 hours post-surgery.

Correct Answer is B

Explanation

Choice A reason: Restricting fluids to 1,200 mL per day is not indicated post-hernia repair unless specific conditions like heart failure exist. Adequate hydration supports recovery and prevents complications like constipation. This restriction is arbitrary and potentially harmful, making it an incorrect plan component.
Choice B reason: Encouraging deep breathing exercises every 2 hours prevents pulmonary complications like atelectasis or pneumonia, common risks post-hernia repair due to anesthesia and pain-limited breathing. This promotes lung expansion and oxygenation, aligning with evidence-based postoperative care, making it the correct intervention.
Choice C reason: Applying a warm compress to the surgical site is not recommended, as it may increase swelling or risk infection in the early postoperative period. Cool compresses, if needed, reduce edema. This intervention lacks evidence and could harm healing, making it inappropriate.
Choice D reason: Limiting ambulation for 48 hours delays recovery, as early mobility post-hernia repair reduces complications like thromboembolism and promotes healing. Patients are typically encouraged to walk within hours, making this restriction counterproductive and against standard postoperative protocols, thus incorrect.

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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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