A nurse is planning care for a client who has overhydration and hyponatremia. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Monitor neurological status.

Administer sodium polystyrene sulfonate as prescribed.

Provide oral hygiene frequently.

Restrict sodium intake as prescribed.

Encourage foods high in protein.

Answer and Explanation

Correct Answer : A,D

Choice A reason:

Monitoring neurological status is a priority intervention for a client who has overhydration and hyponatremia because these conditions can cause cerebral edema, increased intracranial pressure, and altered mental status. The nurse should assess the client for signs of confusion, lethargy, seizures, and coma, and report any changes to the provider.

Choice B reason:

Administering sodium polystyrene sulfonate is not indicated for a client who has overhydration and hyponatremia. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. It has no effect on sodium levels or fluid balance.

Choice C reason:

Providing oral hygiene frequently is a supportive intervention for a client who has overhydration and hyponatremia, but it is not a priority. Oral hygiene can help prevent dry mouth, infections, and discomfort caused by fluid retention and electrolyte imbalance. However, it does not address the underlying causes or complications of the disorder.

Choice D reason:

Restricting sodium intake as prescribed is an essential intervention for a client who has overhydration and hyponatremia. Sodium intake can affect the serum sodium level and the fluid balance in the body. Excessive sodium intake can worsen fluid retention and edema, while inadequate sodium intake can exacerbate hyponatremia. The nurse should follow the provider's orders regarding sodium restriction and educate the client on how to avoid high-sodium foods and beverages.

Choice E reason:

Encouraging foods high in protein is not appropriate for a client who has overhydration and hyponatremia. Protein intake can affect the serum osmolality and the fluid distribution in the body. High-protein foods can increase the osmotic pressure in the blood vessels, drawing more fluid from the interstitial and intracellular spaces. This can worsen overhydration and hyponatremia by diluting the serum sodium level further. The nurse should consult with a dietitian regarding the optimal protein intake for the client.

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Correct Answer is D

Explanation

Choice A reason: Shaving the hair around the insertion site is not recommended because it can cause skin irritation and increase the risk of infection.

Choice B reason:

Obtaining informed consent from the patient is important, but it is not a step that the nurse should perform before inserting the catheter. Informed consent should be obtained by the physician or advanced practice nurse who will perform the procedure.

Choice C reason:

Administering prophylactic antibiotics to the patient is not a routine practice for central venous catheter insertion. Antibiotics may be indicated for patients with certain risk factors, such as immunosuppression, but they should be prescribed by the physician or advanced practice nurse.

Choice D reason:

Placing the patient in Trendelenburg position is an important step that the nurse should perform before inserting the catheter. This position helps to distend the jugular vein and reduce the risk of air embolism during catheter insertion.

A. pH 7.50, PaCO2 40 mm Hg, HCO3- 30 mEq/L. B. pH 7.35, PaCO2 35 mm Hg, HCO3- 24 mEq/L. C. pH 7.25, PaCO2 50 mm Hg, HCO3- 26 mEq/L. D. pH 7.30, PaCO2 30 mm Hg, HCO3- 18 mEq/L.

Correct Answer is A

Explanation

Choice A reason:

pH 7.50, PaCO2 40 mm Hg, HCO3- 30 mEq/L. This choice is correct because it shows a high pH, a normal PaCO2, and a high HCO3-, which are consistent with metabolic alkalosis. Metabolic alkalosis occurs when there is a loss of acid or a gain of base in the body fluids, such as from prolonged nasogastric suctioning. The kidneys try to compensate by excreting more bicarbonate, but this process is slow and incomplete.

Choice B reason:

pH 7.35, PaCO2 35 mm Hg, HCO3- 24 mEq/L. This choice is incorrect because it shows normal values for pH, PaCO2, and HCO3-, which indicate no acid-base imbalance. A client with metabolic alkalosis would have an elevated pH and bicarbonate level.

Choice C reason:

pH 7.25, PaCO2 50 mm Hg, HCO3- 26 mEq/L. This choice is incorrect because it shows a low pH, a high PaCO2, and a normal HCO3-, which are consistent with respiratory acidosis. Respiratory acidosis occurs when there is impaired gas exchange or hypoventilation, leading to an accumulation of carbon dioxide in the blood. The kidneys try to compensate by retaining more bicarbonate, but this process is slow and incomplete.

Choice D reason:

pH 7.30, PaCO2 30 mm Hg, HCO3- 18 mEq/L. This choice is incorrect because it shows a low pH, a low PaCO2, and a low HCO3-, which are consistent with metabolic acidosis. Metabolic acidosis occurs when there is a gain of acid or a loss of base in the body fluids, such as from diabetic ketoacidosis or diarrhea. The lungs try to compensate by increasing the rate and depth of breathing to expel more carbon dioxide, but this process is fast and limited.

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A nurse is planning care for a client who has overhydration and hyponatremia. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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