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.

Answer and Explanation

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.

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Correct Answer is ["B","C","E","F","G"]

Explanation

The correct answer is choiceb. Identify the client using 2 client identifiers,c. Perform hand hygiene,e. Don gloves,f. Check the skin around the face, andg. Assess respiratory function.

Choice A rationale:

Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.

Choice B rationale:

Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.

Choice C rationale:

Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.

Choice D rationale:

Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.

Choice E rationale:

Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.

Choice F rationale:

Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.

Choice G rationale:

Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.

A. Culture for sensitive organisms. B. C-reactive protein level. C. Blood pH level. D. Serum blood glucose level.

Correct Answer is A

Explanation

Choice A rationale:

Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy.

Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance.

Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers.

Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.

Choice B rationale:

Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma.

Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy.

Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.

Choice C rationale:

Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection.

Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections.

Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.

Choice D rationale:

Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections.

Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general.

Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.

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Which action should be included in the teaching plan for a patient with hypernatremia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to set up the oxygen administration and apply the simple face mask. What should the nurse do before applying the face mask? Select all that apply.

Correct Answer is ["B","C","E","F","G"]

Explanation

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Correct Answer is A

Explanation

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Which action should be included in the teaching plan for a patient with hypernatremia?