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","B","C","D","E"]

Explanation

A tracheostomy is a surgical procedure that involves creating an opening in the neck to establish a direct airway to the trachea. It is usually done in patients who require long-term mechanical ventilation or have upper airway obstruction. In case the tracheostomy becomes dislodged, the following equipment should be available to ensure the patient's safety:

Tracheostomy kit setup: This includes a new tracheostomy tube, obturator, and other equipment necessary to replace the dislodged tracheostomy tube.

Suction equipment: Dislodgement of the tracheostomy tube can cause airway obstruction due to the presence of secretions. Suction equipment can be used to remove the secretions and prevent airway obstruction.

Smaller Tracheostomy Tube and Same size Tracheostomy Tube: If the dislodged tracheostomy tube cannot be reinserted or is damaged, having smaller and same size tracheostomy tubes available can be helpful in establishing a new airway.

Ambu bag: This is a manual resuscitation device used to provide positive pressure ventilation to the patient. It can be used in case the patient's breathing is compromised due to airway obstruction.

Oxygen: The patient may require supplemental oxygen if their breathing is compromised due to airway obstruction.

Larger Tracheostomy Tube: A larger tracheostomy tube may not be needed immediately and may be contraindicated in some cases as it can cause trauma to the tracheal wall.

A. The colon is responsible for absorbing water and nutrients. I am now at high risk for ﬂuid and electrolyte imbalances. B. My colon is only responsible for sodium intake. I can eat more salt to ensure I am not deficient. C. The part of my colon that I have left will work overtime to prevent any deficiencies in my electrolytes. D. I am going to start drinking more Gatorade to prevent any imbalances from occurring.

Correct Answer is A

Explanation

The colon is responsible for absorbing water and nutrients.

I am now at high risk for ﬂuid and electrolyte imbalances. This statement demonstrates that the patient understands the function of the gastrointestinal tract in relation to ﬂuid and electrolyte balance. The colon plays an important role in absorbing water and electrolytes from digested food, and after a large portion of the colon has been removed, the patient may be at higher risk for ﬂuid and electrolyte imbalances.

Received message. The correct option is a. The colon is responsible for absorbing water and nutrients. I am now at high risk for ﬂuid and electrolyte imbalances. This statement demonstrates that the patient understands the function of the gastrointestinal tract in relation to ﬂuid and electrolyte balance. The colon plays an important role in absorbing water and electrolytes from digested food, and after a large portion of the colon has been removed, the patient may be at higher risk for ﬂuid and electrolyte imbalances.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are setting up a room for your patient that has a new tracheostomy. Select all of the equipment you need bring with to ensure patient is safe should the tracheostomy become dislodged:

Correct Answer is ["A","B","C","D","E"]

Explanation

JD has been admited after a large portion of his colon has been removed due to cancer Which statement by the patient demonstrates that he understands the function of the Gastrointestinal tract as related to ﬂuid and electrolyte balance.

Correct Answer is A

Explanation

KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

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:

Coughing and Deep breathing is taught to a patient to prevent recurrent pneumonia. She is educated to breathe in deeply first to over expand lung volume: this is called what?

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

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?