Hypernatremia
What is the normal serum sodium level?
Answer:
135–145 mEq/L
Rationale:
This range is necessary to maintain normal fluid balance and nerve and muscle function.
Which assessment finding indicates fluid volume excess?
Answer:
Bounding pulse and crackles.
Rationale:
Excess fluid increases intravascular volume and can cause pulmonary congestion.
What type of leg pain is commonly reported with PVD?
Answer:
Dull leg pain or cramping.
Rationale:
Poor circulation decreases oxygen delivery to tissues.
What should the nurse do before administering antibiotics to a client with suspected pneumonia?
Answer:
Obtain a sputum culture.
Rationale:
Cultures identify the causative organism and should be collected before antibiotics alter results.
What is the normal potassium level?
3.5–5.0 mEq/L.
Rationale:
This range supports normal neuromuscular and cardiac function.
A sodium level of 152 mEq/L indicates what electrolyte imbalance?
Answer:
Hypernatremia.
Rationale:
Any sodium level greater than 145 mEq/L is considered hypernatremia.
What happens to blood pressure in hypervolemia?
Answer:
Blood pressure increases.
Rationale:
The increased circulating volume elevates blood pressure.
Which intervention should be avoided in clients with vascular insufficiency?
Answer:
Soaking feet in warm water.
Rationale:
Soaking increases the risk of skin breakdown and infection.
Why is oxygen often prescribed for clients with pneumonia?
Answer:
To improve oxygenation and treat hypoxia.
Rationale:
Inflammation and secretions impair gas exchange.
A potassium level of 6.8 mEq/L is considered what condition?
Answer:
Hyperkalemia.
Rationale:
A potassium level above 5.0 mEq/L is elevated.
Name two assessment findings associated with hypernatremia.
Answer:
Thirst, dry sticky mucous membranes, flushed skin, irritability, restlessness, decreased urine output.
Rationale:
Elevated sodium causes water to move out of cells, resulting in dehydration and neurological symptoms.
Name three manifestations of hypervolemia.
Answer:
Edema, crackles, weight gain, distended neck veins, bounding pulses.
Rationale:
Excess fluid accumulates in tissues and the lungs.
Name three symptoms of PVD.
Answer:
Cramping, brown pigmentation, edema, ulcers, weak pulses, cool skin.
Rationale:
Decreased circulation leads to tissue changes and impaired healing.
Name three nursing interventions for pneumonia.
Answer:
Administer oxygen, encourage coughing and deep breathing, incentive spirometer, hydration.
Rationale:
These interventions improve airway clearance and oxygenation.
What diagnostic test should be obtained first in severe hyperkalemia?
Answer:
12-lead ECG.
Rationale:
Hyperkalemia can cause life-threatening cardiac dysrhythmias.
Which IV fluids are commonly used to treat hypernatremia?
D5W or 0.45% NaCl.
Rationale:
Hypotonic solutions gradually rehydrate the cells and lower sodium levels safely.
What medication is commonly prescribed for hypervolemia?
Answer:
Furosemide (Lasix).
Rationale:
Loop diuretics remove excess fluid from the body.
What teaching should the nurse provide to a client with PVD?
Answer:
Stop smoking, avoid crossing legs, walk regularly, keep feet clean and dry.
Rationale:
These interventions improve circulation and prevent complications.
What complication should the nurse monitor for in a client with pneumonia?
Answer:
Sepsis.
Rationale:
Pneumonia can progress to a systemic infection.
Name two ECG changes associated with hyperkalemia.
Answer:
Peaked T waves, widened QRS, bradycardia.
Rationale:
Elevated potassium alters cardiac conduction.
Name three causes of hypernatremia.
Answer:
Dehydration, excessive sodium intake, fever, burns, hypertonic IV fluids, Cushing's syndrome.
Rationale:
All of these conditions result in water loss or excess sodium retention.
What nursing interventions are appropriate for a patient with hypervolemia?
Answer:
Restrict fluids, restrict sodium, monitor I&O, monitor daily weights, assess lung sounds, administer diuretics.
Rationale:
These interventions decrease fluid overload and monitor for complications.
When are compression stockings appropriate for clients with PVD?
For venous insufficiency.
Rationale:
Compression improves venous return and decreases edema.
A patient with pneumonia has an oxygen saturation of 84%. What is the priority intervention?
Answer:
Administer oxygen.
Rationale:
Using ABCs, oxygenation is the immediate priority.
Name three treatments for hyperkalemia.
Answer:
Insulin and glucose, Kayexalate, calcium gluconate.
Rationale:
These medications lower potassium or protect the heart from its effects.