Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Restrict oral fluids to 800 to 1,000 mL/day.
Restrict oral fluids to 800 to 1,000 mL/day: Hyponatremia is a characteristic finding in SIADH, and fluid restriction is a key intervention to correct the imbalance.
B. Maintain an IV of 0.45% sodium chloride.
Maintain an IV of 0.45% sodium chloride: Infusing hypertonic (3%) saline may be indicated in severe cases of hyponatremia, but the initial step is fluid restriction.
C. Ensure the client receives a 2 g/day sodium diet.
Ensure the client receives a 2 g/day sodium diet: Dietary sodium restriction is not the primary intervention for SIADH. Fluid restriction is more critical.
D. Administer desmopressin acetate 0.2 mg orally.
Administer desmopressin acetate 0.2 mg orally: Desmopressin acetate is an antidiuretichormone and would exacerbate the retention of water, further decreasing sodium levels. It is not the appropriate intervention for this client.
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Full Explanation
a. Restrict oral fluids to 800 to 1,000 mL/day: Hyponatremia is a characteristic finding in SIADH, and fluid restriction is a key intervention to correct the imbalance.
b. Maintain an IV of 0.45% sodium chloride: Infusing hypertonic (3%) saline may be indicated in severe cases of hyponatremia, but the initial step is fluid restriction.
c. Ensure the client receives a 2 g/day sodium diet: Dietary sodium restriction is not the primary intervention for SIADH. Fluid restriction is more critical.
d. Administer desmopressin acetate 0.2 mg orally: Desmopressin acetate is an antidiuretic
hormone and would exacerbate the retention of water, further decreasing sodium levels. It is not the appropriate intervention for this client.
Similar Questions
A nurse is caring for a client who has dysphagia following a stroke. Which of the following is the priority action for the nurse to take when feeding the client?
A. Encourage the client to take small bites.
Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.
B. Place food in the unaffected side of the mouth.
Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.
C. Offer mouth care before meals.
Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.
D. Place the client in the upright position.
Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.
Full Explanation
a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.
b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.
c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.
d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.
A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?
A. A client taking furosemide for chronic hypertension.
A client taking furosemide for chronic hypertension: Furosemide is a loop diuretic that canlead to hypokalemia, which increases the risk of digoxin toxicity, as hypokalemia potentiates the effects of digoxin on the heart.
B. A client taking a potassium supplement twice a day.
A client taking a potassium supplement twice a day: Potassium supplementation reduces the risk of digoxin toxicity, as hypokalemia is a risk factor for toxicity.
C. A client taking aluminum hydroxide for gastric upset.
A client taking aluminum hydroxide for gastric upset: Aluminum hydroxide is an antacid and does not significantly affect digoxin levels.
D. A client taking chlorpropamide for type 2 diabetes mellitus.
A client taking chlorpropamide for type 2 diabetes mellitus: Chlorpropamide is an oral hypoglycemic agent and does not significantly affect digoxin levels.
Full Explanation
a. A client taking furosemide for chronic hypertension: Furosemide is a loop diuretic that can
lead to hypokalemia, which increases the risk of digoxin toxicity, as hypokalemia potentiates the effects of digoxin on the heart.
b. A client taking a potassium supplement twice a day: Potassium supplementation reduces the risk of digoxin toxicity, as hypokalemia is a risk factor for toxicity.
c. A client taking aluminum hydroxide for gastric upset: Aluminum hydroxide is an antacid and does not significantly affect digoxin levels.
d. A client taking chlorpropamide for type 2 diabetes mellitus: Chlorpropamide is an oral hypoglycemic agent and does not significantly affect digoxin levels.
A nurse is monitoring a client who is 12 hr postoperative following a colectomy. Which of the following findings should the nurse report to the provider?
A. Heart rate 90/min
Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
B. Serum potassium 3.7 g/dL
Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
C. Bowel sounds 10/min
Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
D. Urine output 48 m/2 hr
Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should bereported to the provider.
Full Explanation
a. Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
b. Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
c. Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
d. Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should be
reported to the provider.