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
Respiratory alkalosis is a condition in which the blood pH is elevated due to a decrease in the partial pressure of carbon dioxide (CO2) in the blood. This can occur when a person breathes too rapidly or deeply (hyperventilation), causing them to exhale too much CO2. In this option, the pH is elevated (normal range is 7.35-7.45), the CO2 is low (normal range is 35-45 mmHg), and the bicarbonate (HCO3) level is within the normal range (22-26 mEq/L), which are all consistent with respiratory alkalosis.
Correct Answer is B
Explanation
Hypertonic solutions have a higher concentration of solutes (such as sodium, glucose, or mannitol) than the fluid in the body's cells, causing water to move out of the cells and into the bloodstream. This results in the shrinking of the cells and an increase in extracellular fluid volume.
Examples of hypertonic solutions include 10% dextrose in water (D10W), 3% saline, and 5% dextrose in 0.9% saline.
In contrast, isotonic solutions have the same concentration of solutes as the fluid in the body's cells, and hypotonic solutions have a lower concentration of solutes than the fluid in the body's cells.
Therefore, in this scenario, the nurse should administer a hypertonic solution to the client who requires IV fluids.
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