Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

Dry skin with inelastic turgor.

Apical rate of 110 beats/minute.

Serum sodium of 185 mEq/L (185 mmol/L).

Polyuria and excessive thirst.

Answer and Explanation

The Correct Answer is C

Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.

Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.

Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.

Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.

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Correct Answer is B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

A. Acetaminophen 650 mg PO PRN. B. Olanzapine 30 mg PO at bedtime. C. Thiamine, USP 100 mg PO daily. D. Ondansetron 8 mg IV PRN.

Correct Answer is A

Explanation

Choice A reason: Acetaminophen is hepatotoxic, metabolized by the liver via cytochrome P450 to NAPQI, which depletes glutathione, causing necrosis in hepatitis. A compromised liver from alcohol or viral hepatitis increases toxicity risk, even at standard doses. Contacting the provider ensures safer analgesics, preventing further liver damage in this high-risk client.

Choice B reason: Olanzapine, an antipsychotic, manages schizophrenia by blocking dopamine D2 receptors. It is metabolized by the liver but has low hepatotoxicity risk compared to acetaminophen in hepatitis. No immediate contraindication exists, as it controls psychosis without significantly worsening liver function, making it safe to administer without delay.

Choice C reason: Thiamine (vitamin B1) is essential in hepatitis, particularly with alcohol abuse, preventing Wernicke’s encephalopathy from deficient glucose metabolism. It is liver-safe and beneficial, supporting neurological function without toxicity. Administering thiamine is appropriate, making it unnecessary to contact the provider before implementation.

Choice D reason: Ondansetron, an antiemetic, controls nausea in hepatitis via serotonin 5-HT3 receptor blockade. It is metabolized by the liver but has minimal hepatotoxicity, safe in liver disease. No contraindication exists, as it alleviates symptoms without worsening hepatitis, unlike acetaminophen, which poses significant liver risk.

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Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

Correct Answer is A

Explanation

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