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In Reviewing the Chart of a 15-Year-Old Client Who Suffered

Question 68

Multiple Choice

In reviewing the chart of a 15-year-old client who suffered a head trauma in a sports accident, the nurse notes a serum potassium of 2.8 mEq/L and a serum sodium of 122 mEq/L. What addition to the nursing care plan would be most appropriate for the nurse to make based on this information?


A) Strict intake and output (I&O) each shift.
B) Passive range of motion exercises each shift
C) Six-feeding, small-portion diet
D) Assessment of flank region every 12 hours for kidney tenderness

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