A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
Administer IV morphine sulfate 4 mg every 2 hours PRN.
Dextrose 5% in 0.9% sodium chloride, continuous infusion.
Infuse 5% dextrose in water at 125 mL/hr.
Neurologic assessment Q2 hours.
The Correct Answer is C
Choice A reason: This statement is false. IV morphine sulfate is a pain medication that can be given as needed to the postoperative patient. It does not affect the serum sodium level.
Choice B reason: This statement is false. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can be used to treat hyponatremia, or low serum sodium level. It provides both glucose and sodium to the patient.
Choice C reason: This statement is true. 5% dextrose in water is a hypotonic solution that can cause further dilution of the serum sodium level. It can worsen the hyponatremia and increase the risk of cerebral edema and seizures.
Choice D reason: This statement is false. Neurologic assessment Q2 hours is a necessary intervention for a patient with hyponatremia, as it can monitor for signs of neurologic deterioration such as confusion, lethargy, or coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.4"]
Explanation
The nurse should administer 1.4 mL of Heparin to the patient.
To calculate the number of milliliters (mL) the nurse should administer, we can use the following steps:
Step 1: Calculate the total amount of Heparin available in mL
Heparin concentration: 5,000 units per mL
Ordered Heparin dose: 7,000 units
Total mL of Heparin needed = Ordered dose / Heparin concentration
Total mL = 7,000 units / 5,000 units per mL = 1.4 mL
Correct Answer is C
Explanation
Choice A reason: This statement is false. The patient’s radial pulse is 105 beats/min is not the assessment data that will require the most rapid response by the nurse. A high pulse rate can indicate dehydration, anxiety, or fever, but it is not a life-threatening condition.
Choice B reason: This statement is false. There is sediment and blood in the patient’s urine is not the assessment data that will require the most rapid response by the nurse. Sediment and blood in the urine can indicate kidney damage, infection, or trauma, but they are not an immediate complication of hyponatremia.
Choice C reason: This statement is true. There are crackles throughout both lung fields is the assessment data that will require the most rapid response by the nurse. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli, which can impair gas exchange and cause respiratory distress. Crackles can be a sign of pulmonary edema, a serious complication of hyponatremia that requires prompt treatment.
Choice D reason: This statement is false. The blood pressure increases from 120/80 to 142/94 mm Hg is not the assessment data that will require the most rapid response by the nurse. A high blood pressure can indicate fluid overload, stress, or pain, but it is not a critical condition.
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