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 A

Explanation

A. Instructing the client in the use of the PCA pump directly addresses the severe pain by allowing the client to self-administer analgesia as needed, which provides immediate relief and is crucial for effective pain management post-surgery.
B. Assisting the client in changing positions may offer temporary relief but does not address the underlying pain, which should be managed primarily through medication.
C. Initiating CPM is not an appropriate first step for managing severe pain. CPM is used for improving joint mobility and should only be considered after effective pain management is established.
D. Applying ice might provide some temporary relief, but it is not a substitute for effective pain control through medication. Addressing the pain with PCA is the priority.

A. Determine if the expected outcomes were realistic. B. Review related professional standards of care. C. Obtain current client data to compare with expected outcomes. D. Modify the nursing interventions to achieve the client's goals.

Correct Answer is C

Explanation

A. Determining if the expected outcomes were realistic is important but comes after comparing the actual client data with the expected outcomes. If the outcomes were unrealistic, it would be identified during this comparison.
B. Reviewing professional standards of care is important for ensuring that care meets quality standards but is not the immediate next step after reviewing the expected outcomes.
C. Obtaining current client data to compare with expected outcomes is the next step to assess whether the client’s condition has improved, worsened, or remained the same. This comparison is crucial for evaluating the effectiveness of the nursing care.
D. Modifying nursing interventions should be done based on the evaluation of client data and outcomes. It is a subsequent step after assessing whether the outcomes have been met.

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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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