A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

Hypertension

Blurred vision

Constipation

Muscle cramps

Answer and Explanation

The Correct Answer is D

A. Hypertension: Hyponatremia typically does not cause high blood pressure. In fact, low sodium levels can lead to fluid shifts and hypotension in severe cases, rather than hypertension. Monitoring blood pressure is important, but hypertension is not an expected finding of hyponatremia.

B. Blurred vision: Blurred vision is not a classic symptom of hyponatremia. While severe electrolyte imbalances can affect neurological function, visual changes are more commonly associated with hypernatremia or other conditions affecting the eyes.

C. Constipation: Constipation is not directly linked to low sodium levels. Hyponatremia primarily affects neuromuscular and neurological function, rather than gastrointestinal motility.

D. Muscle cramps: Muscle cramps are a common manifestation of hyponatremia due to the disruption of sodium’s role in neuromuscular excitability. Low sodium levels can cause involuntary muscle contractions, weakness, and twitching.

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Correct Answer is ["A","D","E"]

Explanation

A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.

B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.

C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.

D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.

E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.

F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.

A. Rinse the client's skin with hot water. B. Keep the clients skin area moist. C. Apply barrier cream to the client's cleansed skin. D. Apply a thin layer of cornstarch to the client's skin.

Correct Answer is C

Explanation

A. Rinse the client's skin with hot water: Hot water can damage the skin’s protective barrier, causing irritation and increasing the risk of breakdown. Using lukewarm water is safer and helps maintain skin integrity while cleansing the area.

B. Keep the client’s skin area moist: Excess moisture from urine or feces contributes to maceration and increases the risk of skin breakdown. The skin should be kept clean and dry, not intentionally moist, to prevent irritation and pressure injury.

C. Apply barrier cream to the client's cleansed skin: Barrier creams protect the skin from prolonged exposure to urine and stool, helping to prevent incontinence-associated dermatitis. Applying the cream after cleansing creates a protective layer, maintaining skin integrity and reducing irritation.

D. Apply a thin layer of cornstarch to the client's skin: Cornstarch can clump when in contact with moisture and may promote fungal growth. It is not recommended for protecting skin from incontinence-related irritation and may worsen skin breakdown.

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A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

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