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 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.

A. Put a hat in the toilet to collect proper output. B. Assess your patient’s lower extremities and lungs for ﬂuid retention. C. Educate her on the importance of writing down all ﬂuids she is drinking. D. Document the numbers anyway, there is a probable error with the intake number.

Correct Answer is B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

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Naxlex Comprehensive Predictor Exams

A patient who is ordered a ﬂuid restriction of 1000ml ﬂuid restriction. He is on the list for a kidney transplant due to kidney failure. His mouth feels dry during the day. and he wants to know how he can moisten his mouth without going over his restriction:

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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