Electrolytes Question #37

Question

A client has a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?

Answers

  1. Encourage fluids orally.
    • Rationale:
  2. Administer 10% saline solution IVPB.
    • Rationale:
  3. Administer antidiuretic hormone intranasally.
    • Rationale:
  4. Place on seizure precautions.
    • Rationale:

Overview

Explanation

The correct answer is D. Clients with low sodium levels are at risk for seizures as a complication. The lower the sodium level, the greater the risk for seizures. When a client has a low sodium level, fluids are not given as this may further decrease the level. An antidiuretic hormone could cause water retention and hypertonic saline solutions should only be used very cautiously, because if the sodium levels increase too rapidly, a massive fluid shift can occur in the body, resulting in neurological damage and heart failure.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale