The Nurse’s Role in Patient Care Management

Every question here, with the answer

1. A patient is newly identified as having dilutional hyponatremia. Which nursing actions should the nurse anticipate or perform to provide safe care? Select all that apply.

   1. Confirm whether the hyponatremia is due to excess free water or sodium loss.
   2. Delay serum sodium checks until the patient develops obvious symptoms.
   3. Perform an hourly neurological exam.
   4. Anticipate an order to restrict fluids.
   5. Monitor intake and output closely.

   Answer: Confirm whether the hyponatremia is due to excess free water or sodium loss., Perform an hourly neurological exam., Anticipate an order to restrict fluids., Monitor intake and output closely.

   Dilutional hyponatremia requires confirming the cause because treatment differs, close neurological monitoring because mental confusion may occur, close input/output monitoring, and likely fluid restriction. Delaying serum sodium checks is unsafe because frequent sodium monitoring is expected until the hyponatremia resolves.

2. The nurse is caring for several stable patients. Which patient should the nurse prioritize for more frequent monitoring?

   1. A patient who reports that pain has resolved after an intervention.
   2. A patient with no new complaints and unchanged vital signs.
   3. A patient who is currently stable but has decreasing urine output and a concerning laboratory trend.
   4. A patient whose daily weight and intake/output are unchanged.

   Answer: A patient who is currently stable but has decreasing urine output and a concerning laboratory trend.

   A stable patient who is showing cues of worsening clinical status should be prioritized because early recognition can prevent deterioration. The other patients do not demonstrate a new or worsening cue in the scenario.

3. A patient with an acute respiratory illness has increased work of breathing. The nurse is monitoring for a respiratory acid-base imbalance. Which assessment data are most important for the nurse to monitor?

   1. Serum sodium level and net fluid balance.
   2. Respiratory rate, work of breathing, and breath sounds.
   3. Serum calcium level and muscle tone.
   4. Daily weight, edema, and skin turgor.

   Answer: Respiratory rate, work of breathing, and breath sounds.

   For respiratory acidosis or alkalosis, the nurse should focus on arterial blood gas findings and respiratory assessment findings. Weight, edema, sodium, calcium, and muscle tone are important for other fluid or electrolyte problems but are not the key respiratory acid-base assessment set.

4. The nurse is assessing a patient for possible fluid volume imbalance. Which cues are most directly associated with fluid imbalance? Select all that apply.

   1. Cardiac arrhythmias.
   2. Skin turgor changes.
   3. Changes in muscle tone.
   4. Urine output changes.
   5. Change in the patient’s weight.

   Answer: Skin turgor changes., Urine output changes., Change in the patient’s weight.

   Fluid imbalance cues include changes in weight, urine output, and skin turgor. Cardiac arrhythmias and muscle tone changes are more specifically described as cues for electrolyte imbalance.

5. A telephone triage nurse speaks with the parent of a child under age 2 who has been vomiting, cannot keep fluids down, has a fever, and has abdominal pain. What is the nurse’s best recommendation?

   1. Recommend that the child be evaluated in the emergency department.
   2. Encourage the parent to wait until morning because vomiting is usually self-limited.
   3. Tell the parent to focus only on stopping the vomiting before seeking care.
   4. Advise the parent to offer larger amounts of fluid at one time.

   Answer: Recommend that the child be evaluated in the emergency department.

   A child under age 2 with vomiting and inability to take fluids is at increased risk for dehydration and can worsen quickly, so evaluation in the emergency department is the safest recommendation. Waiting, focusing only on stopping vomiting, or pushing larger amounts of fluid does not address the risk described in the section.

6. The nurse is writing expected outcomes for patients at risk for fluid, electrolyte, or acid-base imbalances. Which outcomes are measurable and time-limited? Select all that apply.

   1. Patient will decrease sodium intake by 50 percent within the next two weeks.
   2. Patient will have a net even fluid balance within the next twelve hours.
   3. Patient’s PaCO2 will increase by 5 mm Hg within the next two hours.
   4. Patient will understand diet teaching.
   5. Patient will feel better soon.

   Answer: Patient will decrease sodium intake by 50 percent within the next two weeks., Patient will have a net even fluid balance within the next twelve hours., Patient’s PaCO2 will increase by 5 mm Hg within the next two hours.

   Measurable outcomes include a specific target and a time frame, such as net fluid balance in twelve hours, PaCO2 change in two hours, or sodium intake reduction within two weeks. Feeling better soon and understanding teaching are not stated in measurable terms with a specific time frame.