Medical Surgical Sodium Na+ #8

Question

The nurse is caring for a client with a feeding tube who has been experiencing loose watery stools. The client has poor skin turgor, tachycardia, lethargy, and hyperactive reflexes. Which intervention would the nurse include in the plan of care?

Answers

  1. Monitor intake, output, and daily weight
    • Rationale:

      This answer is correct because this client’s data indicates hypernatremia and dehydration; therefore, the appropriate nursing intervention is to monitor intake, output, and daily weights.

  2. Apply restraints to protect the feeding tube
    • Rationale:

      This answer is not correct because there is no indication that this client is attempting to remove the feeding tube or is otherwise a threat to self or others; therefore, the application of restraints is not an appropriate nursing intervention for this client.

  3. Monitor hypertonic intravenous therapy
    • Rationale:

      This answer is not correct because the client would not be receiving hypertonic intravenous therapy when demonstrating signs of dehydration; therefore, this is not an appropriate action by the nurse.

  4. Assess electrocardiogram readings
    • Rationale:

      This answer is not correct because while the client is experiencing tachycardia, there is no indication of cardiac dysrhythmia that would necessitate a need for electrocardiogram (ECG) readings; therefore, this is not an appropriate action by the nurse.

Overview

Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving based on the client’s current clinical data. Based on the current data, this client is exhibiting signs of hypernatremia (i.e., increased serum sodium levels) and dehydration (i.e., a dangerous loss of body fluid caused by illness, sweating, or inadequate intake).

Explanation

Learning Outcomes

Based on the current data, this client is exhibiting signs of hypernatremia (i.e., increased serum sodium levels) and dehydration (i.e., a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). This is likely the result of fluid losses caused by diarrhea. The most appropriate nursing intervention is to measure and record intake and output and daily weight.

Test Taking Tip

Consider the client’s current clinical presentation and appropriate nursing interventions to address any issues to answer this question correctly.

Video Rationale