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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Stopping suctioning may not be necessary if the oxygen saturation is stable and within acceptable limits. The key is to ensure that the suctioning procedure is not adversely affecting oxygenation.
B. Repositioning the pulse oximeter clip is a good practice to ensure accurate readings, especially if there is any concern about the reliability of the current measurement. An accurate oxygen saturation reading is essential for assessing the impact of the suctioning procedure.
C. Completing the suctioning procedure may be appropriate if the oxygen saturation is stable. However, it’s important to ensure that the oxygen saturation readings are accurate and reliable before continuing.
D. Applying an oxygen mask may be necessary if the client's oxygen saturation drops, but there is no indication that the oxygen saturation has decreased. Repositioning the oximeter clip is a more immediate step to ensure accurate readings.

A. Power flush with 60 mL to remove mucous obstructions. B. Slowly irrigate catheter with saline using an infusion pump. C. Clamp the catheter for 30 minutes prior to irrigating. D. Use a sterile syringe to irrigate with 20 mL normal saline.

Correct Answer is D

Explanation

A. Power flushing with 60 mL of solution can create excessive pressure in the bladder, increasing the risk of trauma or forcing bacteria into the urinary tract. Gentle irrigation is preferred to safely remove clots and sediment without causing injury.

B. Using an infusion pump to slowly irrigate the catheter may not allow proper control of pressure and volume, which can damage the bladder mucosa. Manual irrigation allows the nurse to assess resistance and stop if obstruction or discomfort occurs.

C. Clamping the catheter for 30 minutes before irrigation can increase bladder pressure and cause discomfort or potential reflux of urine into the kidneys. Routine pre-irrigation clamping is not recommended unless specifically ordered for retention management.

D. Using a sterile syringe with 20 mL of normal saline allows controlled, gentle irrigation to remove clots and sediment. Sterile technique reduces the risk of introducing pathogens, and the small volume minimizes bladder trauma while effectively clearing the catheter.

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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?

Nursing Test Bank

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Explanation

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