A patient is receiving 3% NaCl solution for correction of hyponatremia.For which of the following will the nurse assess?
Hypokalemia.
Hypovolemia.
Fluid overload.
Hypernatremia.
The Correct Answer is C
Choice A rationale
Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.
Choice B rationale
Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.
Choice C rationale
Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.
Choice D rationale
Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale: A blood glucose level of 55 mg/dL is critically low, indicating hypoglycemia. Immediate intervention is required to prevent potential complications such as loss of consciousness, seizures, or even death. Hypoglycemia in individuals with type 1 diabetes can be life-threatening and requires prompt treatment with fast-acting carbohydrates to restore normal blood glucose levels.
Choice B rationale: The client's report of shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia. These symptoms correlate with the dangerously low blood glucose level and indicate an urgent need for intervention. Addressing these symptoms quickly can prevent further deterioration of the client's condition.
Choice C rationale: While the slight increase in temperature to 37.8°C (100°F) is noteworthy, it does not necessitate immediate intervention compared to the hypoglycemic event. Monitoring for any signs of infection or other issues is important, but it is not the highest priority in this scenario.
Choice D rationale: An oxygen saturation of 97% on room air is within normal limits and does not require immediate follow-up. There are no signs of respiratory distress or hypoxia that would necessitate urgent intervention in this case.
Correct Answer is B
Explanation
Choice A rationale
Hypokalemia involves low potassium levels and is not treated with sodium polystyrene sulfonate. This drug is used to treat elevated potassium levels.
Choice B rationale
Hyperkalemia indicates high potassium levels in the blood. Sodium polystyrene sulfonate (Kayexalate) works by exchanging sodium ions for potassium ions in the intestines, thereby lowering blood potassium levels.
Choice C rationale
Hyponatremia, or low sodium levels, is not treated with sodium polystyrene sulfonate, which targets potassium removal.
Choice D rationale
Hypocalcemia refers to low calcium levels and is unrelated to the action of sodium polystyrene sulfonate, which addresses potassium imbalance.
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