A nurse is caring for an endurance athlete admitted for altered mental status. The client drank large amounts of water during a recent long-distance running event. The client is confused, complaining of a headache, and has a full bounding pulse. The nurse develops the plan of care based on the expectation that the client's lab work will demonstrate which of the following abnormalities?

Serum potassium 5.0 mEq/L

Serum osmolality 294 mmol/kg

Serum sodium of 127 mEq/L

Serum hemoglobin 15.7 grams/dL

Answer and Explanation

The Correct Answer is C

A. Serum potassium 5.0 mEq/L: This is within the normal range for serum potassium (3.5-5.0 mEq/L). While potassium levels are important, they are not the primary concern with symptoms of confusion and a bounding pulse due to excessive water intake.
B. Serum osmolality 294 mmol/kg: This value is within the normal range for serum osmolality (275-295 mmol/kg). Elevated or normal osmolality would not be expected in a case of water intoxication, which dilutes serum electrolytes.
C. Serum sodium of 127 mEq/L: A serum sodium level of 127 mEq/L indicates hyponatremia, a condition often caused by excessive water intake that dilutes the sodium in the bloodstream. Symptoms such as confusion, headache, and a full bounding pulse are consistent with hyponatremia, making this the expected abnormality.
D. Serum hemoglobin 15.7 grams/dL: This is within the normal range for hemoglobin (12-16 grams/dL for women and 13.8-17.2 grams/dL for men). Hemoglobin levels would not be expected to change significantly due to water intoxication.

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Correct Answer is B

Explanation

A. Tell the client he can no longer have any more pain medication: This is not appropriate. The client’s severe pain needs to be managed, but the current vital signs suggest a need for careful evaluation before administration.
B. Notify the prescribing physician: This is the correct choice. The client's blood pressure and respiratory rate are significantly low, which could be exacerbated by morphine. The physician needs to be informed to reassess pain management and possibly adjust the treatment.
C. Administer half the dose of morphine, 2 mg IV: Given the client's low blood pressure and respiratory rate, any morphine administration could worsen these issues. Adjusting the dose without physician guidance is not appropriate.
D. Administer 4 mg of morphine IV as ordered: Administering the full dose without addressing the client’s low blood pressure and respiratory rate could lead to severe complications.

A. Teach the client a relaxation technique to use until the next dose is due. B. Obtain an order for an immediate-release opioid for breakthrough pain. C. Explain to the client that the medication being administered lasts for 12 hours. D. Assess the client's vital signs and administer the next dose of opioids early.

Correct Answer is B

Explanation

A. Teach the client a relaxation technique to use until the next dose is due: While relaxation techniques can be helpful in managing pain, they are not sufficient for severe pain rated 9/10. The client requires more immediate pharmacological intervention.
B. Obtain an order for an immediate-release opioid for breakthrough pain: This is the most appropriate action. Immediate-release opioids are specifically used to manage breakthrough pain in clients on sustained-release opioid therapy. It addresses the client's severe pain effectively and promptly.
C. Explain to the client that the medication being administered lasts for 12 hours: Simply explaining the duration of the medication does not address the client's current severe pain. Effective pain management requires action, not just education.
D. Assess the client's vital signs and administer the next dose of opioids early: Administering the next dose early can lead to inappropriate dosing schedules and potential overdose. It is important to follow the prescribed dosing regimen and manage breakthrough pain appropriately.

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Naxlex Comprehensive Predictor Exams

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

Correct Answer is B

Explanation

A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Correct Answer is B

Explanation

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Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

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