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 B
Explanation
Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with fluid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.
Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.
Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.
Correct Answer is C
Explanation
c. Sip the water he is allowed to have slowly to make it last throughout the day.
Option a is not recommended as hard candies may contain sugar and artificial sweeteners, which can be harmful to the patient's health.
Option b is not recommended because caffeinated tea has diuretic properties that can increase urine output, leading to further dehydration.
Option d is not recommended as Gatorade is a sports drink that contains high amounts of sugar and electrolytes, which can lead to fluid overload and imbalances.
Sipping the water slowly can help the patient moisten his mouth without going over his fluid restriction. This approach can also help him pace his fluid intake throughout the day, which can be beneficial for maintaining proper hydration levels and managing fluid overload.
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