A nurse is contributing to the plan of care for a client who has hypernatremia. Which of the following interventions should the nurse recommend to include in the plan?

Restrict fluid intake.

Restrict sodium intake.

Administer a potassium supplement.

Administer a laxative.

Answer and Explanation

The Correct Answer is B

A. Restrict fluid intake: This would not be appropriate for hypernatremia, as fluid intake should generally be increased to help dilute serum sodium levels.
B. Restrict sodium intake: This is correct as reducing sodium intake helps manage hypernatremia by decreasing the amount of sodium in the bloodstream.
C. Administer a potassium supplement: Potassium supplementation is not indicated for hypernatremia and could lead to imbalances.
D. Administer a laxative: A laxative is not relevant for managing hypernatremia and does not address the underlying issue of high sodium levels.

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Correct Answer is D

Explanation

A. A padded tongue blade: A padded tongue blade is not recommended as it can cause injury to both the client and the nurse. It is a common misconception that it should be used during a seizure, but it does not prevent injury.
B. Anticonvulsant medication: While important for managing seizures, anticonvulsant medication is not an equipment item to be placed at the bedside. It is typically administered as per the prescription and monitored by healthcare providers.
C. A nasogastric tube: A nasogastric tube is not relevant for seizure precautions and is used for different medical purposes, such as feeding or gastric decompression.
D. A suction machine: This is correct as a suction machine is essential to clear the airway in case of aspiration during or after a seizure. It helps in maintaining airway patency and preventing complications.

A. Leaning forward B. Prone C. Lithotomy D. Knees elevated

Correct Answer is A

Explanation

A. Leaning forward: This is correct as the client should be in a sitting position with arms resting on a table or a support to allow the lungs to expand and make the pleural space more accessible for the procedure.
B. Prone: This is incorrect because the prone position would not provide the necessary access to the pleural space and would be uncomfortable for the procedure.
C. Lithotomy: This is incorrect as the lithotomy position is used for gynecological procedures, not for thoracentesis.
D. Knees elevated: This is incorrect because elevating the knees is not a suitable position for thoracentesis and does not facilitate access to the pleural space.

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A nurse is contributing to the plan of care for a client who has hypernatremia. Which of the following interventions should the nurse recommend to include in the plan?

Nursing Test Bank

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