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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory eﬀort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.

Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.

Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.

The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.

A. Inspiration B. Expiration C. Intake D. Chest

Correct Answer is A

Explanation

Deep breathing or "diaphragmatic breathing" is a technique used to prevent recurrent pneumonia and improve lung function. During deep breathing, the patient is instructed to inhale deeply, expanding their lung volume as much as possible. This process is called inspiration.

Expiration, on the other hand, is the process of exhaling or breathing out air from the lungs. Intake refers to the process of taking in air or breathing in, while chest is a part of the body where the lungs are located.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who recently had surgery on her left hip. What should be the priority teaching for the patient after surgery to prevent complications?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

Your patient has a CMP drawn to determine their electrolytes. Only part of the values have resulted including the Na+ which is 121 mEq/l. What type of electrolyte imbalance is the patient having?

The nurse is obtaining a pulse oximetry reading for a client admited with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 91%. what action should the nurse perform?

The Practical Nurse (PN) assessing a client for the nursing diagnosis of Impaired Verbal Communication is aware that the least number of defining characteristics for this diagnosis is:

A patient newly diagnosed with heart failure understands that heart failure means there is a lack of sufficient blood supply to the patient's tissue throughout the body tells you that the is responsible for pumping blood from the hear t to the lest of the body.

RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

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

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:

A client suﬀering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?