a patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone siadh the nurse should notify the health
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Nursing Elites

HESI RN

Adult Health 2 HESI Quizlet

1. A patient who has small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the healthcare provider about which assessment finding?

Correct answer: C

Rationale: The correct answer is C, a serum sodium level of 120 mEq/L. Hyponatremia is the most important finding to report in SIADH. SIADH causes water retention and a decrease in serum sodium levels. Hyponatremia can lead to confusion and other central nervous system effects and requires treatment. Adequate kidney function is indicated by a urinary output of at least 30 mL/hr. A hematocrit level of 42% is normal. Weight gain is expected due to water retention in SIADH.

2. How should the nurse interpret the following arterial blood gas results for a patient who had a tracheostomy placed after a motor vehicle crash: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

Correct answer: D

Rationale: The patient's pH of 7.48 indicates alkalosis, and the low PaCO2 of 32 mm Hg suggests a respiratory cause. The HCO3 level is normal, ruling out metabolic causes. Therefore, the correct interpretation is respiratory alkalosis. Options A, B, and C are incorrect as they do not align with the pH and PaCO2 values provided.

3. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

Correct answer: B

Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.

4. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?

Correct answer: B

Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.

5. At 01:00 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

Correct answer: A

Rationale: The client has a plan to read until feeling sleepy, indicating an intention to sleep. Therefore, offering a PRN sedative-hypnotic (C) is unnecessary, especially since it is a stronger sleep aid. Option (D) is not needed as the client already has a plan to address his sleeplessness. Assessing the surgical dressing (B) is not relevant to the client's immediate need for sleep. Leaving the room and closing the door (A) is the appropriate action to provide a conducive environment for the client to rest.

Similar Questions

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?
A patient who is taking a potassium-wasting diuretic for the treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

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