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 ["C","D","E"]

Explanation

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

A. Keep the medication and see if the client will want to take it later. B. Credit the medication back and put it in the client's medication box. C. Explain that since the medication is a controlled substance it must be taken. D. Have another nurse watch the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

A. The medication should not be kept or stored once it has been removed from its original packaging, especially if it’s not administered. Proper disposal or return to the pharmacy is required.
B. The medication should not be put back in the client’s medication box due to safety and contamination concerns.
C. While controlled substances need careful management, the client’s refusal must be respected, and the medication must be disposed of properly if not administered.
D. Having another nurse witness the disposal of the medication ensures that it is done according to protocols and provides accountability. This practice helps maintain the integrity and safety of medication handling.

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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

Naxlex Comprehensive Predictor Exams

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is D

Explanation

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