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 C

Explanation

A. Doxazosin .5 mg PO at bedtime is incorrect. The dose should be written as "0.5 mg" to include the leading zero, following proper medication administration guidelines.

B. Lorazepam 0.5 mg PO PRN at bedtime is incorrect. "PRN" should include a specific indication (e.g., anxiety, insomnia. for when it is to be administered.

C. Heparin 5000 U subcutaneous every 8 hr is correct. The prescription is clear and includes the correct dose, route, and frequency of administration.

D. MgSO4 10 g PO daily is incorrect. Magnesium sulfate is typically administered intravenously, not orally, unless specified otherwise for specific conditions, and the dosage is quite high for oral administration.

A. "We will frequently check the top of his ears for sores." B. "We can turn the oxygen up to 10 when he has trouble breathing." C. "We can use petroleum jelly to keep his nares moist." D. "We will need to remove the nasal cannula when he is eating."

Correct Answer is A

Explanation

A. Frequently checking the top of the ears for sores is correct. The nasal cannula tubing can cause pressure injuries behind the ears over time. The family should check for redness or sores and use protective padding or adjust the tubing as needed.

B. Turning the oxygen up to 10 when the client has trouble breathing is incorrect. Oxygen flow rates should be adjusted only as prescribed by the provider. Increasing the flow rate without guidance can lead to complications, such as oxygen toxicity in clients with chronic respiratory conditions.

C. Using petroleum jelly to keep the nares moist is incorrect. Petroleum-based products are flammable and should not be used with oxygen therapy. Instead, a water-based lubricant should be used to prevent nasal dryness.

D. Removing the nasal cannula when eating is incorrect. Clients using a nasal cannula can continue wearing it while eating, as it allows them to receive oxygen continuously. If needed, a healthcare provider can recommend adjustments to oxygen flow during meals.

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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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