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.

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Correct Answer is B

Explanation

When someone has asthma, their lungs may produce a wheezing sound when they breathe in and out. Narrowed airways and restricted air movement through the lungs may be responsible for the wheezing sound.

A. What do you think that the child might have ingested?’ B. ’At what time did the child ingest the substance?' C. ‘Induce vomiting while you wait for emergency personnel to arrive.' D. ‘Check breathing and heart rate.’

Correct Answer is A

Explanation

In case of suspected ingestion of a poisonous substance, the priority response of the poison control nurse should be to assess the child's vital signs, especially breathing and heart rate, to determine if the child is experiencing any immediate life-threatening symptoms. This information will help the nurse determine the appropriate course of action, such as whether to instruct the caregiver to perform CPR or to immediately call for emergency medical assistance.

Asking about the substance ingested and the time of ingestion are also important pieces of information to gather, but they should not take priority over assessing the child's vital signs. Inducing vomiting is generally not recommended unless instructed to do so by a medical professional, as it can cause further harm if the substance ingested is corrosive or caustic.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides care for the client with an asthma crisis experiencing hypoxia. Which lung sound would the nurse expect to auscultate on the physical assessment?

Correct Answer is B

Explanation

The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

Correct Answer is A

Explanation

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which arterial blood gas data does the nurse anticipate finding in this patient?

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?

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)

A patient’s hemoglobin is severely low and she is complaining of being overly tired and fatigued. You are educating her on the role hemoglobin has with oxygenation and perfusion. You will know she understands the role of hemoglobin when she tells you hemoglobin transports:

MA is a 85 year old female who is admited to the hospital with Pneumonia. Education has begun on proper breathing techniques to expand lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. Which device will help her achieve this as educated by the nurse?

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?