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 A

Explanation

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

A. Mg2 – 20 mEq/L B. Na+ - 123 mEq/L C. Ca2 – 10.0 mg/dl D. K+ - - 3.1 mEq/L

Correct Answer is D

Explanation

Atrial fibrillation is a common arrhythmia, and diuretics are often used in the management of patients with this condition to help control ﬂuid balance. However, diuretics can cause electrolyte imbalances, especially hypokalaemia (low potassium levels), which can lead to muscle cramps and other complications.

A Complete Metabolic Panel (CMP) is a blood test that measures various electrolytes, glucose, and other important components. Among the options given, the most likely lab value to be abnormal in Patient MK's case is a low level of potassium (K+), which is consistent with her symptoms and diuretic use. Option d, K+ -

1. mEq/L, is the correct option as it represents a low level of potassium, which is defined as a value less than 3.5 mEq/L.

Option a, Mg2 – 20 mEq/L, represents high magnesium levels, which are not typically associated with diuretic use or muscle cramps. Option b, Na+ - 123 mEq/L, represents low sodium levels, which are less likely to occur with diuretic use, and are typically associated with other conditions. Option c, Ca2 – 10.0 mg/dl, represents normal calcium levels and is not typically aﬀected by diuretic use.

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Naxlex Comprehensive Predictor Exams

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Correct Answer is A

Explanation

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

Correct Answer is D

Explanation

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