Author Question: A client's serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse ... (Read 230 times)

magmichele12 · **on:** Jun 25, 2018

A client's serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse plan for this client?

Select all that apply.
A) Monitor heart rate and rhythm.
B) Elevate the head of the bed.
C) Instruct on a low-sodium diet.
D) Administer diuretics as prescribed.
E) Administer potassium supplement as prescribed.

Question 2

While planning care for a client who has been hospitalized for 2 weeks, the nurse selects the nursing diagnosis of Risk for Disuse Syndrome due to the extended hospitalization.

The nurse is assisting the client with a bath and wants to encourage full range of motion in all the client's joints. Which activity will best support range of motion for the client's hand and arm?
A) Having the client brush the hair and teeth
B) Moving the wash basin farther toward the foot of the bed to encourage the client to reach for the items
C) Moving each of the client's hand and arm joints through passive range of motion
D) Giving the client a washcloth to wash the face

tmlewis4706 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: C, D

For an elevated sodium level, the electrolyte will need to be restricted, in the form of a low-sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. This is not known at this time and would not be a routine intervention with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance. More information is needed before this intervention would be planned or implemented.

Answer to Question 2

Answer: A

The best range of motion is the natural movement of the client's joints in normal activity. Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. The wash basin should be close to the client to prevent overreaching and possible falls. Passive range of motion is a second-best choice after normal use of the joints.