A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

Nausea and vomiting

Altered mental status

Dysrhythmias

Hypothermia

Answer and Explanation

The Correct Answer is B

A. Nausea and vomiting: Nausea and vomiting can be present with hypernatremia (high sodium levels), but they are not the most prominent or specific symptom. The client may experience these symptoms, but they are usually accompanied by other signs.

B. Altered mental status: This is a common manifestation of hypernatremia. The elevated sodium level causes an osmotic imbalance, leading to water shifting out of cells, which results in neurological symptoms, including confusion, lethargy, or seizures.

C. Dysrhythmias: Dysrhythmias can occur with electrolyte imbalances, including hypernatremia, but the primary symptoms related to sodium levels are more often neurological in nature, such as confusion or altered mental status, rather than dysrhythmias specifically.

D. Hypothermia: Hypernatremia typically causes an increase in body temperature, not hypothermia. Elevated sodium levels cause dehydration, which could contribute to increased body temperature rather than cooling.

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Correct Answer is A

Explanation

A. “I will consider what is going to benefit the most people when making decisions.”: This is correct. Utilitarianism is an ethical theory that focuses on the greatest good for the greatest number of people. Decisions are made based on the outcomes that benefit the most individuals, even if they might not always align with individual preferences.

B. "I will respect the decision of a client who has a chronic illness to stop treatment.": This reflects the principle of autonomy, not utilitarianism. Autonomy focuses on respecting an individual's right to make their own decisions, rather than the greater good.

C. "I will place a higher emphasis on human dignity than on the needs of a group.": This statement leans more toward a deontological perspective, which prioritizes individual rights and dignity over collective benefits.

D. "I will withhold a terminal diagnosis from a client who has cancer.": This reflects a paternalistic approach, where decisions are made by healthcare providers for the patient, which is not a principle of utilitarianism. Utilitarianism would consider the benefits and harms of full disclosure to the patient, rather than withholding information.

A. Verify the amount of TPN solution the client is receiving every 4 hr. B. Place the client in Sims' position for catheter insertion C. Use clean technique when changing the catheter dressing D. Prepare the client for a chest x-ray to verify catheter placement

Correct Answer is D

Explanation

A. Verifying the amount of TPN solution the client is receiving every 4 hours is incorrect. While monitoring the TPN infusion rate is important, the rate and amount are typically verified at the start of the infusion and with each new bag change, not every 4 hours.

B. Placing the client in Sims' position for catheter insertion is incorrect. The preferred position for central venous catheter insertion is Trendelenburg or supine with a slight head turn, which helps dilate the veins and reduce the risk of air embolism.

C. Using clean technique when changing the catheter dressing is incorrect. Central venous catheter care requires sterile technique to prevent infections, including catheter-related bloodstream infections (CRBSIs).

D. Preparing the client for a chest x-ray to verify catheter placement is correct. A chest x-ray is required to confirm correct catheter placement before TPN administration to ensure the catheter tip is in the superior vena cava and to rule out complications like pneumothorax.

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A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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