The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
White blood cell count.
Serum sodium levels.
Serum potassium levels.
Creatinine clearance.
The Correct Answer is B
A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Adjusting the hand grips is necessary to ensure that the client can bear weight comfortably through the arms without placing stress on the wrists or shoulders, so avoiding this adjustment is incorrect.
B. Holding the crutch 6 inches to the side is a common guideline, but it is not as crucial as ensuring the correct fit of the crutches to avoid axillary nerve damage and ensure proper posture.
C. The crutch should fit 2 finger widths below the axilla to prevent pressure on the brachial plexus nerves, which can lead to nerve damage. This demonstrates an understanding of proper crutch fit and use.
D. Walking with the arms fully extended is incorrect; the arms should be slightly bent at the elbows to allow for proper weight distribution and movement.
Correct Answer is ["0.8"]
Explanation
To calculate the volume of hydromorphone to administer, we can use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
In this case:
- Dose = 3 mg
- Concentration = 4 mg/mL
Plugging in the values:
Volume (mL) = 3 mg / 4 mg/mL = 0.75 mL
Therefore, the nurse should administer 0.8 mL of hydromorphone to the client.
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