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A client is prone to hyponatremia. Which factors should the nurse identify that can
precipitate hyponatremia? Select all that apply.
Wound drainage
Diuretic therapy
Gastrointestinal (GI) suction
Parenteral infusion of 0.9% sodium chloride
Inappropriate anti-diuretic hormone (ADH) secretion -CORRECT ANSWER6 Wound
Drainage
Diuretic Therapy
GI Suction
Inappropriate Anti-Diuretic Hormone Secretion
Rationale:
Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics
interfere with sodium reabsorption in the nephrons and have the side effect of
hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI
suction. With the syndrome of inappropriate anti-diuretic hormone (SIADH), high levels
of the anti-diuretic hormone (ADH) are produced, causing the body to retain water
instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride,
an isotonic solution, should be compatible with body fluids; if given in excess, it may
lead to hypernatremia.
The nurse is assessing the respiratory status of the client at 2-hour intervals as a
nursing safety priority. Which condition is affecting the client?
Hypokalemia
Hyperkalemia
Hyponatremia
Hypernatremia -CORRECT ANSWER6 Hypokalemia
Rationale:
In case of hypokalemia, the nurse should assess the respiratory status of the client
every 2 hours. In case of hyperkalemia, the nurse should notify the healthcare team if
, the heart rate falls below 60 beats per minute or T waves become spiked. In case of
hyponatremia, the nurse should be aware of muscle weakness in the client and
immediately check respiratory effectiveness. In case of hypernatremia, the nurse should
assess the client hourly for excessive losses of fluid, sodium, or potassium.
The nurse is preparing a blood transfusion for a client with renal failure. Why does
anemia often complicate renal failure?
1. Increase in blood pressure
2. Decrease in erythropoietin
3. Increase in serum phosphate levels
4. Decrease in serum sodium concentration -CORRECT ANSWER6 2. Decrease in
erythropoietin
Rationale:
The hormone erythropoietin, produced by the kidneys, stimulates the bone marrow to
produce red blood cells. In renal failure there is a deficiency of erythropoietin that often
results in the client developing anemia. Therefore the nurse is instructed to administer
blood. In renal failure, increased blood pressure is due to impairment of renal
vasodilator factors and is not treated by administration of blood. Phosphate is retained
in the body during renal failure, causing binding of calcium leading to done
demineralization, not anemia. Increase in urinary sodium concentration and decrease in
serum sodium concentration trigger the release of renin from the juxtaglomerular cells.
A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action
should the nurse implement first?
1. Call the laboratory to repeat the test.
2. Take vital signs and notify the healthcare provider.
3. Inform the cardiac arrest team to place them on alert.
4. Take an electrocardiogram and have lidocaine available -CORRECT ANSWER6 2.
take vs and notify healthcare provider
rationale:
Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias.
The healthcare provider should be notified because medical intervention may be
necessary. A repeat laboratory test will take time and probably reaffirm the original
results; the client needs immediate attention. The cardiac arrest team is always on alert
and will respond when called for a cardiac arrest. Taking an electrocardiogram and
having lidocaine available are insufficient interventions.
A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been
told by the primary healthcare provider that hemodialysis is necessary. Which clinical
manifestation indicates the need for hemodialysis?
1. Ascites
2. Acidosis