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

Explanation

A. This is the most appropriate response. Clients with COPD often have chronically elevated carbon dioxide levels, which can lead to a compensatory decrease in the oxygen saturation level. A reading of 91% may be within their normal range.

A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

Correct Answer is A

Explanation

A. Respiratory acidosis.

COPD is a chronic lung disease that can lead to an accumulation of carbon dioxide (CO2) in the body. This can cause respiratory acidosis, a condition in which the blood pH is lower than normal due to an excess of CO2.

In respiratory acidosis, the partial pressure of carbon dioxide (PaCO2) in the blood is increased and the pH is decreased. The kidneys atempt to compensate for the acidosis by excreting more acid in the urine and retaining more bicarbonate, but this compensation is usually not enough to fully correct the problem.

Metabolic alkalosis (option B) is a condition in which the blood pH is higher than normal due to an excess of bicarbonate in the blood. This is usually caused by loss of acid from the body, such as through vomiting or use of diuretics.

Respiratory alkalosis (option C) is a condition in which the blood pH is higher than normal due to a decrease in PaCO2. This can be caused by hyperventilation, which leads to excessive elimination of CO2 from the lungs.

Metabolic acidosis (option D) is a condition in which the blood pH is lower than normal due to an excess of acid in the blood. This can be caused by a variety of factors, including kidney failure or lactic acidosis.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which arterial blood gas data does the nurse anticipate finding in this patient?

Correct Answer is A

Explanation

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