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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The left ventricle is responsible for pumping oxygen-rich blood from the heart to the rest of the body. In heart failure, the left ventricle is weakened and unable to pump blood efficiently, resulting in reduced blood flow to the body's tissues. This can lead to symptoms such as fatigue, shortness of breath, and swelling in the legs and feet. Treatment for heart failure may include medications, lifestyle changes, and in some cases, surgical interventions such as a heart transplant.
Correct Answer is C
Explanation
An Incentive Spirometer is a device that helps patients take deep breaths and improve their lung function. It encourages patients to take deep breaths and to hold them for a few seconds. The device also helps to monitor and measure lung volume. By using an incentive spirometer, MA can expand her lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. This is an important technique to help prevent pneumonia and other respiratory complications.
The other options mentioned, 4L of oxygen via Nasal Cannula, Fluter Valve, and Abdominal Binder, are not appropriate devices to help MA achieve proper breathing techniques and expand lung volume. 4L of oxygen via Nasal Cannula is used to provide supplemental oxygen to patients who have difficulty breathing. Fluter Valve is a handheld device used for airway clearance in patients with chronic obstructive pulmonary disease (COPD) or cystic fibrosis. An abdominal binder is a wrap that is placed around the abdomen to support the abdominal muscles and help reduce pain after surgery or injury. These devices do not help improve lung function and are not appropriate for MA's condition.
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