Which action should be included in the teaching plan for a patient with hypernatremia?
Drink plenty of water whenever thirsty.
Review food labels for sodium content.
Monitor daily urine output volume.
Use salt tablets after strenuous exercise.
The Correct Answer is B
Drinking plenty of water whenever thirsty is not the most appropriate action for a patient with hypernatremia. While it's important to stay hydrated, excessive water intake can potentially worsen hypernatremia by diluting blood sodium levels further. This is because the body tries to balance sodium levels by either retaining water or excreting it through urine. In hypernatremia, the body is already short on water relative to sodium, so consuming too much water can exacerbate the imbalance.
Choice B rationale:
Reviewing food labels for sodium content is crucial for managing hypernatremia. It empowers patients to make informed choices and limit their sodium intake.
Sodium is a major contributor to hypernatremia, and reducing dietary sodium intake is a key strategy to lower blood sodium levels.
By carefully reading food labels and selecting low-sodium options, patients can effectively manage their sodium intake and promote a gradual return to normal sodium levels.
This approach addresses the root cause of hypernatremia and promotes long-term control of blood sodium levels.
Choice C rationale:
Monitoring daily urine output volume can be helpful in tracking fluid status, but it's not the primary action for managing hypernatremia.
While urine output can provide insights into fluid balance, it doesn't directly address the underlying issue of excessive sodium. Focusing on dietary sodium intake is a more direct and effective approach to correcting hypernatremia.
Choice D rationale:
Using salt tablets after strenuous exercise is not recommended for patients with hypernatremia.
Salt tablets are intended to replenish electrolytes lost through sweating, but they can worsen hypernatremia by further increasing sodium levels.
Patients with hypernatremia should focus on reducing sodium intake, not increasing it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.
Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.
Choice B rationale:
While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.
The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.
Choice C rationale:
Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.
This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.
The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.
This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.
Choice D rationale:
Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.
Correct Answer is ["B","E","G"]
Explanation
B. Position the patient with the head of the bed elevated. Rationale:
Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.
Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.
Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.
E. Teach the patient to cough at least once an hour. Rationale:
Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.
Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.
G. Assist the patient in ambulating safely. Rationale:
Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.
Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.
Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.
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