Medical Surgical Sodium Na+ #2
A client with a serum sodium level of 115 mEq/L has been receiving an intravenous infusion of 3% normal saline (NS) at 50 mL/hr for 16 hours. This morning the client feels tired and short of breath. Which action should the nurse make a priority?
- Slow the infusion
This answer is not correct because while slowing the infusion may be an appropriate nursing action, this is not the priority. Assessment is always the priority to determine what action to take next.
- Check the latest sodium level
This answer is not correct because while checking the latest serum sodium level is a responsible action, this is not the nurse’s priority based on the current data exhibited by the client (i.e., fatigue, dyspnea). These findings are indicative of hypervolemia and must be addressed immediately.
- Notify the healthcare provider
This answer is not correct because it is not appropriate to notify the health care provider without first assessing the client; therefore, this is not the priority action by the nurse.
- Assess for signs of fluid overload
This answer is correct because a complication of hypertonic sodium solution administration is fluid overload; therefore, the nurse must assess the client’s for clinical manifestations indicative of this complication as the priority action.
Hypertonic saline refers to any saline solution with a concentration of sodium chloride (NaCl) higher than physiologic (0.9%). The nurse must closely monitor all clients who receive continuous IV infusions for clinical manifestations that are indicative of complications.
The nurse must closely monitor all clients who receive continuous IV infusions for clinical manifestations that are indicative of complications. This client is prescribed 3% normal saline (NS) at 50 mL/hr, a hypertonic saline solution, and is at risk for hypervolemia. Fatigue and dyspnea are both indicators of hypervolemia thus require additional assessment from the nurse; therefore, the priority action is to assess for signs of fluid overload.
Test Taking Tip
Priority indicates that while all choices may be appropriate only one should be implemented first by the nurse.