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A nurse is collecting data from a client who has a sodium level of 128 mEq/L (136-145 mEq/L) Which of the following manifestations should the nurse expect?

Increased appetite

Hyporeflexia

Constipation

Headache

Answer and Explanation

The Correct Answer is D

A. Increased appetite: Hyponatremia does not typically cause increased appetite.

B. Hyporeflexia: Severe hyponatremia may lead to neurological symptoms, but reflex changes are less common.

C. Constipation: This is unrelated to sodium levels.

D. Headache: Hyponatremia causes cellular swelling, including in the brain, leading to headache, nausea, and neurological symptoms.

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Correct Answer is D

Explanation

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

A. Vital signs B. skin turgor C. Daily input and output D. Daily weights

Correct Answer is D

Explanation

A. Vital signs: Vital signs can reflect changes in fluid status, but they are not always sensitive to small shifts in fluid balance and can be affected by many other factors like medications.

B. Skin turgor: Skin turgor can be useful for assessing dehydration but is not a reliable indicator for tracking fluid balance over time, especially in older adults where skin elasticity naturally declines.

C. Daily input and output: Monitoring intake and output is useful, but it is not the most reliable for evaluating overall fluid balance, especially in cases of insensible loss or shifts in third spaces.

D. Daily weights: Weighing the patient daily is the most reliable method for monitoring fluid balance because it directly reflects changes in fluid retention or loss, particularly in acute or chronic conditions like heart failure or dehydration.

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A nurse is collecting data from a client who has a sodium level of 128 mEq/L (136-145 mEq/L) Which of the following manifestations should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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