Author Question: A patient receives 3 NaCl solution for correction of hyponatremia. Which assessment is most ... (Read 39 times)

Yi-Chen · **on:** Jun 25, 2018

A patient receives 3 NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema

Question 2

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

a. Give the prescribed PRN lorazepam (Ativan).
b. Start the prescribed PRN oxygen at 2 to 4 L/min.
c. Administer the prescribed normal saline bolus and insulin.
d. Encourage the patient to take deep, slow breaths with guided imagery.

olderstudent · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

Answer to Question 2

ANS: C
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.