A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?
Maintain the prescribed fluid restriction.
Withhold the next scheduled dose of treatment.
Increase neurologic checks to every 2 hours.
Assess for increasing fluid volume overload.
The Correct Answer is A
Choice A rationale
Maintaining the prescribed fluid restriction is crucial in the management of SIADH. Fluid restriction helps to prevent further dilution of sodium in the blood, which can exacerbate the symptoms of SIADH34.
Choice B rationale
Withholding the next scheduled dose of treatment is not necessarily the appropriate intervention based on the increase in serum sodium level. The treatment plan should be adjusted based on the patient’s overall clinical picture and in consultation with the healthcare provider.
Choice C rationale
Increasing neurologic checks to every 2 hours is not directly related to the increase in serum sodium level. While neurologic checks are important in monitoring the overall health status of the patient, they are not specifically indicated based on the serum sodium level alone.
Choice D rationale
Assessing for increasing fluid volume overload is not the appropriate intervention based on the increase in serum sodium level. SIADH is characterized by water retention, not fluid volume overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Prepare ice packs for placement in the patient’s axillary area.This response is crucial because the symptoms described—muscle rigidity and hyperthermia—are indicative ofmalignant hyperthermia, a serious reaction that can occur after the administration of succinylcholine, especially in conjunction with certain anesthetics. Immediate cooling measures, such as applying ice packs, are essential to help reduce the patient's elevated body temperature.
Rationale for Other Options:
- A. Call the PACU nurse to prepare for prolonged ventilatory support.: While preparing for ventilatory support may be necessary later, immediate action to address hyperthermia is critical.
- B. Hold a prescription for dantrolene until the fever is reduced.: Dantrolene is the antidote for malignant hyperthermia and should be administered as soon as possible rather than held.
- D. Determine if prescribed antibiotics were administered preoperatively.: This action is not relevant to the immediate management of malignant hyperthermia.
Correct Answer is A
Explanation
Choice A rationale
The client’s presentation of chest pain radiating to the left arm, shortness of breath, and diaphoresis are classic symptoms of a myocardial infarction (heart attack)56. Morphine is often administered in this situation to relieve pain and reduce the workload of the heart.
Choice B rationale
Oxycodone is a strong opioid medication used to treat severe pain. However, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice C rationale
Hydromorphone is another strong opioid medication used to treat severe pain. Like oxycodone, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice D rationale
Fentanyl is a potent opioid pain reliever. While it can be used in the management of severe pain, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
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