A nurse is planning care for a client who has hypernatremia. Which of the following interventions should the nurse include in the plan?
Administer hypotonic IV fluids.
Monitor blood glucose levels.
Provide oral care every 4 hours.
Increase dietary intake of potassium.
The Correct Answer is A
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Choice A reason:
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Administering hypotonic IV fluids is an appropriate intervention for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than the blood, so they can help dilute the excess sodium and rehydrate the cells.
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Choice B reason:
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Monitoring blood glucose levels is not directly related to hypernatremia, although it may be indicated for other reasons, such as diabetes. Hypernatremia can be caused by uncontrolled diabetes, but it is not a consequence of high blood glucose levels.
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Choice C reason:
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Providing oral care every 4 hours is a supportive measure for a client who has hypernatremia, but it is not a specific intervention to correct the electrolyte imbalance. Oral care can help relieve thirst and dry mouth, which are common symptoms of hypernatremia, but it does not address the underlying cause of fluid loss or sodium gain.
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Choice D reason:
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Increasing dietary intake of potassium is not helpful for a client who has hypernatremia. Potassium is another electrolyte that plays a role in fluid balance and nerve function, but it is not affected by hypernatremia. In fact, increasing potassium intake may worsen the condition by causing further dehydration or hyperkalemia (high potassium levels)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason:
Monitoring daily weight is an important action for the nurse to take because it reflects the fluid status of the client. A sudden increase in weight indicates fluid retention, while a sudden decrease indicates fluid loss. The nurse should weigh the client at the same time every day, using the same scale and clothing.
Choice B reason:
Restricting sodium intake is another action that the nurse should take because sodium attracts water and increases fluid volume. The nurse should limit or avoid foods that are high in sodium, such as processed meats, canned soups, cheese, pickles, and salty snacks. The nurse should also educate the client about reading food labels and choosing low-sodium alternatives.
Choice C reason:
Administering diuretics as prescribed is a third action that the nurse should take because diuretics increase urine output and reduce fluid volume. The nurse should monitor the client's electrolyte levels, blood pressure, and urine output before and after giving diuretics. The nurse should also inform the client about the possible side effects of diuretics, such as dehydration, hypotension, hypokalemia, and ototoxicity.
Choice D reason:
Encouraging oral fluids is not an action that the nurse should take because it would worsen the fluid volume excess. The nurse should limit or restrict oral fluids as ordered by the provider. The nurse should also measure and record all fluid intake and output accurately.
Choice E reason:
Elevating the head of the bed is a fourth action that the nurse should take because it improves respiratory function and reduces pulmonary congestion. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client's comfort and tolerance. The nurse should also monitor the client's oxygen saturation, breath sounds, and dyspnea.
Correct Answer is A
Explanation
Choice A reason:
Feeling less thirsty is a sign of improved hydration status and a positive outcome of IV fluid therapy. Thirst is a subjective symptom of dehydration that is triggered by increased osmolality of the blood or decreased blood volume. When IV fluids are administered, they restore the fluid balance and reduce the thirst sensation.
Choice B reason:
Urine that is dark and concentrated is a sign of inadequate hydration and a negative outcome of IV fluid therapy. Urine color and concentration are influenced by the amount of fluid intake and output. When a person is dehydrated, the kidneys conserve water and produce less urine that is more concentrated and darker in color. When IV fluids are administered, they increase the urine output and dilute the urine, making it lighter in color.
Choice C reason:
A heart rate of 110 beats per minute is a sign of tachycardia and a negative outcome of IV fluid therapy. Tachycardia is an abnormal increase in heart rate that can be caused by dehydration, among other factors. Dehydration reduces the blood volume and lowers the blood pressure, which triggers the heart to beat faster to maintain adequate perfusion to the vital organs. When IV fluids are administered, they increase the blood volume and pressure and normalize the heart rate.
Choice D reason:
Having a headache and dizziness is a sign of cerebral dehydration and a negative outcome of IV fluid therapy. Headache and dizziness are common symptoms of dehydration that result from reduced blood flow to the brain and increased osmolality of the blood. When IV fluids are administered, they improve the cerebral perfusion and osmotic balance and relieve the headache and dizziness.
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