The nurse is caring for a client with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?
A)Draw blood for arterial blood gases (ABGs).
B)Administer 5% hypertonic saline intravenously.
C)Administer acetaminophen 650 mg orally.
D)Send client for computed tomography (CT) of the head.

Question

Quizplus · Accepted Answer

The client's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

The Nurse Is Caring for a Client with Possible Cerebral