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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering packed RBCs is important but is not the highest priority. Stabilizing the client’s hemodynamic status is critical first.
Choice B rationale
Elevating the client's feet can help with blood circulation but does not address the immediate need to stabilize blood pressure and fluid volume.
Choice C rationale
Initiating a dopamine IV infusion can help with hypotension, but it is not the first action. Stabilizing the client with fluids is a higher priority.
Choice D rationale
Increasing the client's IV fluid rate is the highest priority to address hypotension and ensure adequate blood volume before administering blood products or other medications. .
Correct Answer is C
Explanation
Choice A rationale
While heartburn can occur shortly after eating, it is the frequent episodes of heartburn and regurgitation that are more commonly associated with hiatal hernia.
Choice B rationale
Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) can occur with other esophageal conditions but are not the primary symptoms of hiatal hernia.
Choice C rationale
Frequent bouts of heartburn and regurgitation after food intake are classic symptoms of hiatal hernia, due to the herniation of the stomach through the diaphragm allowing acid to reflux into the esophagus.
Choice D rationale
Bloating and postprandial fullness can occur, but they are not as commonly associated with hiatal hernia as heartburn and regurgitation.
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