You receive report from the oﬀ going nurse that patient L K is admited with hyponatremia. the nurse states he is becoming increasingly confused as the day goes on and management is considering restraining the patient, so he does not become a harm to himself. You assess the patient and note that the IV ﬂuids hanging are 0.33% NaCI. What should you do next?

Bring the patient to the nurse s station so he can be watched until he regains orientation.

Get an order for additional lab work.

Call the doctor and get an order for restraints.

Disconnect the IV ﬂuids immediately they are dropping his Na+ levels.

Answer and Explanation

The Correct Answer is B

Hyponatremia is a condition where the sodium levels in the blood are abnormally low. It can cause confusion, seizures, and even coma in severe cases. The IV ﬂuids hanging are 0.33% NaCI, which means they have a low sodium concentration, and may be contributing to the patient's hyponatremia.

Given that the patient is becoming increasingly confused, it is important to assess his mental status and monitor him closely to prevent harm. However, restraining the patient should not be the first course of action. Instead, the nurse should focus on identifying the underlying cause of the hyponatremia and taking appropriate steps to address it.

Therefore, the next step would be to get an order for additional lab work to assess the patient's electrolyte levels and identify the cause of the hyponatremia. This will help to guide further treatment and management decisions for the patient.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.

A. Patient will exchange cigaretes for vaping in 5 days B. Patient will stop smoking cigaretes within 7 days C. Patient will smoke only a few cigaretes each day D. Patient will not smoke cigaretes while wearing oxygen

Correct Answer is D

Explanation

This outcome is the most appropriate because smoking can worsen COPD and lead to further respiratory complications, while oxygen is often used to help patients with COPD breathe more easily. Smoking while wearing oxygen can be very dangerous and increases the risk of fire and explosion. Therefore, the best expected outcome is for the patient to completely avoid smoking while wearing oxygen.

Option a is not a recommended solution since vaping may also worsen COPD symptoms and there is limited evidence of its safety in people with respiratory conditions. Option b is a good outcome, but it may not be achievable in such a short time frame. Option c is not an ideal outcome as even a few cigaretes can cause harm to the respiratory system, exacerbate symptoms, and slow down the healing process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Correct Answer is A

Explanation

MK is admited with COPD exacerbation. Your nursing care plan reads Impaired Gas Exchange, related to smoking 1 PPD of cigaretes. AED pursed lip breathing shortness of breath. Which is the best expected outcome for this diagnosis.

Correct Answer is D

Explanation

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which ﬂuid imbalance?

A client with renal disease requires IV ﬂuids. It is important for the nurse to:

The nurse scaring for a patient who will be needing a blood transfusion. The nurse knows that the universal recipient of blood would be considered blood type:

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topics would be most important to include: (Select Al That Apply)

The Practical Nurse (PN) assessing a client for the nursing diagnosis of Impaired Verbal Communication is aware that the least number of defining characteristics for this diagnosis is:

Your patient is ordered an EKG upon admission to the hospital. She is very scared and states she has never had one of these diagnostic tests before. Which answer is most appropriate by the nurse regarding EKG.

The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?