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 B
Explanation
Choice A rationale
While it’s important for patients with peripheral neuropathy to protect their feet, it’s recommended that they wear shoes at all times to prevent injury. Being barefoot, even inside the house, can increase the risk of foot injuries.
Choice B rationale
Regular foot exams are crucial for patients with peripheral neuropathy. Family members can assist with these exams, helping to identify any changes or injuries that may require medical attention.
Choice C rationale
Heating pads are not typically recommended for patients with peripheral neuropathy. Due to the loss of sensation in their feet, they may not realize if the pad is too hot, which could lead to burns.
Choice D rationale
Soaking feet in lukewarm water for extended periods is not typically recommended for patients with peripheral neuropathy. Prolonged exposure to water can dry out the skin and increase the risk of injury.
Correct Answer is B
Explanation
Choice A rationale
Using an incentive spirometer is generally recommended for respiratory conditions to improve lung function, not specifically for a client with hydronephrosis and a history of renal calculi.
Choice B rationale
Monitoring the urinary stream for decreased output is crucial for a client with hydronephrosis and a history of renal calculi. Hydronephrosis is a condition characterized by urine accumulation in the kidney, which can lead to decreased urine output. Therefore, monitoring urinary output can help detect any potential complications or worsening of the condition.
Choice C rationale
Restricting physical activities is not typically necessary for a client with hydronephrosis and a history of renal calculi unless specified by the healthcare provider. It’s more important to focus on maintaining overall health and well-being.
Choice D rationale
Reporting when hematuria becomes pink-tinged is not the most relevant instruction for a client with hydronephrosis and a history of renal calculi. While it’s important to report any changes in urine color, monitoring urinary output (Choice B) is more directly related to the client’s condition.
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